MIDWEST SURGICAL HOSPITAL
1. Target Overview & Investment Thesis
MIDWEST SURGICAL HOSPITAL is a 19-bed suburban community hospital in DOUGLAS, NE with $70.1M in net patient revenue and a 36.2% operating margin. The hospital serves a payer mix of 50.9% Medicare, 1.2% Medicaid, and 47.9% commercial.
Thesis: Turnaround. Our ML models identify $5.2M in annual EBITDA improvement potential from RCM optimization across 5 levers, lifting margin from 36.2% to 43.6% (+736bps).
| Net Revenue HCRIS | $70.1M |
| Current EBITDA COMPUTED | $25.4M |
| Operating Margin COMPUTED | 36.2% |
| Occupancy HCRIS | 15.8% |
| Revenue / Bed COMPUTED | $3.7M |
| Net-to-Gross HCRIS | 33.7% |
| Distress Probability ML | 52.8% |
2. Market Context & Competitive Position
NE has 98 Medicare-certified hospitals with a median operating margin of -6.3%. The target's margin of 36.2% places it above the state median. Among 69 size-comparable peers (10-38 beds), the median margin is -5.5%. The target performs in line with or above peers.
3. RCM Performance Analysis — Comparable Hospitals
Comps selected by bed count (10-38), prioritizing same-state peers. 69 hospitals in the comp set.
| Hospital | State | Beds | Revenue | Margin |
|---|---|---|---|---|
| MIDWEST SURGICAL HOSPITAL (Target) | NE | 19 | $70.1M | 36.2% |
| NEBRASKA ORTHOPAEDIC HOSPITAL | NE | 24 | $112.1M | 22.5% |
| BEATRICE COMMUNITY HOSPITAL | NE | 25 | $84.6M | -1.2% |
| LINCOLN SURGICAL HOSPITAL | NE | 20 | $80.9M | 18.8% |
| PHELPS MEMORIAL HEALTH CENTER | NE | 25 | $69.0M | 8.2% |
| SIDNEY REGIONAL MEDICAL CENTER | NE | 19 | $68.0M | 0.8% |
| COMMUNITY HOSPITAL ASSOCOCIATI | NE | 25 | $56.0M | -7.4% |
| NEBRASKA SPINE HOSPITAL | NE | 34 | $55.9M | 49.5% |
| YORK GENERAL HOSPITAL INC | NE | 25 | $52.3M | -1.9% |
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: $5.2M (736bps margin improvement).
| Lever | Current | Target | EBITDA Impact | Margin | Ramp |
|---|---|---|---|---|---|
| Net Collection Rate | 93.5% | 97.0% | $1.5M | +210bp | 18mo |
| Cost to Collect | 4.5% | 2.5% | $1.4M | +200bp | 12mo |
| Denial Rate Reduction | 12.0% | 6.5% | $1.4M | +198bp | 12mo |
| A/R Days Reduction | 5200.0% | 3800.0% | $853K | +122bp | 9mo |
| Clean Claim Rate | 88.0% | 96.0% | $45K | +6bp | 6mo |
5. EBITDA Bridge
| Current EBITDA | $25.4M |
| + RCM Uplift | +$5.2M |
| Pro Forma EBITDA | $30.5M |
| Current Margin | 36.2% |
| Pro Forma Margin | 43.6% |
| WC Released (1x) | $2.7M |
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 | $39.1M | $219.1M | 5.61x | 41.2% |
| Base (11x exit) | 10.0x | 11.0x | $39.1M | $253.7M | 6.49x | 45.4% |
| Bull Case | 9.0x | 11.0x | $35.2M | $283.4M | 8.06x | 51.8% |
| Bull (12x exit) | 9.0x | 12.0x | $35.2M | $319.5M | 9.09x | 55.5% |
| Bear Case | 11.0x | 10.0x | $43.0M | $180.6M | 4.20x | 33.3% |
| Bear (11x exit) | 11.0x | 11.0x | $43.0M | $212.6M | 4.95x | 37.7% |
7. Key Risks & Mitigants
| Severity | Risk Factor | Mitigant |
|---|---|---|
| Medium | Low occupancy | At 15.8%, 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 52.8% 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
- 69 hospitals with 10-38 beds
- Same-state prioritization (n=70)
- Comp margins: P25=-13.0% / P50=-5.5% / P75=0.5%
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.