AVERA MARSHALL REGIONAL MEDICAL CTR
1. Target Overview & Investment Thesis
AVERA MARSHALL REGIONAL MEDICAL CTR is a 25-bed suburban community hospital in LYON, MN with $115.2M in net patient revenue and a -17.0% operating margin. The hospital serves a payer mix of 27.7% Medicare, 3.3% Medicaid, and 69.0% commercial.
Thesis: Turnaround. Our ML models identify $8.5M in annual EBITDA improvement potential from RCM optimization across 5 levers, lifting margin from -17.0% to -9.6% (+736bps).
| Net Revenue HCRIS | $115.2M |
| Current EBITDA COMPUTED | $-19.6M |
| Operating Margin COMPUTED | -17.0% |
| Occupancy HCRIS | 36.4% |
| Revenue / Bed COMPUTED | $4.6M |
| Net-to-Gross HCRIS | 43.2% |
| Distress Probability ML | 47.3% |
2. Market Context & Competitive Position
MN has 141 Medicare-certified hospitals with a median operating margin of -3.6%. The target's margin of -17.0% places it below the state median. Among 92 size-comparable peers (12-50 beds), the median margin is -2.0%. The target's below-peer margin suggests operational improvement opportunity.
3. RCM Performance Analysis — Comparable Hospitals
Comps selected by bed count (12-50), prioritizing same-state peers. 92 hospitals in the comp set.
| Hospital | State | Beds | Revenue | Margin |
|---|---|---|---|---|
| AVERA MARSHALL REGIONAL MEDICA (Target) | MN | 25 | $115.2M | -17.0% |
| CUYUNA REGIONAL MEDICAL CENTER | MN | 25 | $180.8M | -4.0% |
| ST. MARYS REGIONAL HEALTH CENT | MN | 36 | $167.8M | 3.1% |
| MAYO CLINIC HEALTH SYSTEM - RE | MN | 27 | $149.3M | 1.8% |
| ESSENTIA HEALTH VIRGINIA | MN | 49 | $132.0M | -5.0% |
| NEW ULM MEDICAL CENTER | MN | 24 | $128.6M | 4.2% |
| LAKEWOOD HEALTH SYSTEM | MN | 25 | $124.7M | 0.2% |
| NORTHFIELD CITY HOSPITAL | MN | 37 | $121.8M | -8.4% |
| GRAND ITASCA CLINIC AND HOSPIT | MN | 34 | $117.7M | 5.3% |
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: $8.5M (736bps margin improvement).
| Lever | Current | Target | EBITDA Impact | Margin | Ramp |
|---|---|---|---|---|---|
| Net Collection Rate | 93.5% | 97.0% | $2.4M | +210bp | 18mo |
| Cost to Collect | 4.5% | 2.5% | $2.3M | +200bp | 12mo |
| Denial Rate Reduction | 12.0% | 6.5% | $2.3M | +198bp | 12mo |
| A/R Days Reduction | 5200.0% | 3800.0% | $1.4M | +122bp | 9mo |
| Clean Claim Rate | 88.0% | 96.0% | $74K | +6bp | 6mo |
5. EBITDA Bridge
| Current EBITDA | $-19.6M |
| + RCM Uplift | +$8.5M |
| Pro Forma EBITDA | $-11.1M |
| Current Margin | -17.0% |
| Pro Forma Margin | -9.6% |
| WC Released (1x) | $4.4M |
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 | $-30.1M | $-44.4M | 0.00x | -100.0% |
| Base (11x exit) | 10.0x | 11.0x | $-30.1M | $-58.7M | 0.00x | -100.0% |
| Bull Case | 9.0x | 11.0x | $-27.1M | $-40.5M | 0.00x | -100.0% |
| Bull (12x exit) | 9.0x | 12.0x | $-27.1M | $-52.1M | 0.00x | -100.0% |
| Bear Case | 11.0x | 10.0x | $-33.2M | $-77.0M | 0.00x | -100.0% |
| Bear (11x exit) | 11.0x | 11.0x | $-33.2M | $-95.5M | 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 |
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
- 92 hospitals with 12-50 beds
- Same-state prioritization (n=93)
- Comp margins: P25=-8.7% / P50=-2.0% / P75=3.5%
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.