RED RIVER BEHAVIORAL HEALTH SYSTEM
1. Target Overview & Investment Thesis
RED RIVER BEHAVIORAL HEALTH SYSTEM is a 70-bed under-performing / distressed in GRAND FORKS, ND with $9.4M in net patient revenue and a -13.2% operating margin. The hospital serves a payer mix of 18.2% Medicare, 20.0% Medicaid, and 61.7% commercial.
Thesis: Turnaround. Our ML models identify $701K in annual EBITDA improvement potential from RCM optimization across 5 levers, lifting margin from -13.2% to -5.7% (+743bps).
| Net Revenue HCRIS | $9.4M |
| Current EBITDA COMPUTED | $-1.2M |
| Operating Margin COMPUTED | -13.2% |
| Occupancy HCRIS | 55.8% |
| Revenue / Bed COMPUTED | $135K |
| Net-to-Gross HCRIS | 25.3% |
| Distress Probability ML | 51.3% |
2. Market Context & Competitive Position
ND has 52 Medicare-certified hospitals with a median operating margin of -9.3%. The target's margin of -13.2% places it below the state median. Among 2205 size-comparable peers (35-140 beds), the median margin is -3.1%. The target's below-peer margin suggests operational improvement opportunity.
3. RCM Performance Analysis — Comparable Hospitals
Comps selected by bed count (35-140), prioritizing same-state peers. 2205 hospitals in the comp set.
| Hospital | State | Beds | Revenue | Margin |
|---|---|---|---|---|
| RED RIVER BEHAVIORAL HEALTH SY (Target) | ND | 70 | $9.4M | -13.2% |
| MIDWESTERN REGIONAL MEDICAL CE | IL | 73 | $1.38B | 80.5% |
| CONTRA COSTA REGIONAL MEDICAL | CA | 124 | $595.0M | -29.2% |
| SMDC MEDICAL CENTER | MN | 118 | $519.2M | -7.1% |
| RANCHO LOS AMIGOS NATL.REHAB.C | CA | 83 | $512.6M | 41.9% |
| WENTWORTH DOUGLASS HOSPITAL | NH | 118 | $500.9M | 10.7% |
| NORTHWESTERN LAKE FOREST HOSPI | IL | 124 | $494.3M | -13.8% |
| MCHS - SOUTHWEST MINNESOTA REG | MN | 118 | $473.6M | -9.8% |
| USC NORRIS CANCER HOSPITAL | CA | 60 | $468.7M | 19.1% |
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: $701K (743bps margin improvement).
| Lever | Current | Target | EBITDA Impact | Margin | Ramp |
|---|---|---|---|---|---|
| Net Collection Rate | 93.5% | 97.0% | $198K | +210bp | 18mo |
| Denial Rate Reduction | 12.0% | 6.5% | $190K | +201bp | 12mo |
| Cost to Collect | 4.5% | 2.5% | $189K | +200bp | 12mo |
| A/R Days Reduction | 5200.0% | 3800.0% | $115K | +122bp | 9mo |
| Clean Claim Rate | 88.0% | 96.0% | $10K | +10bp | 6mo |
5. EBITDA Bridge
| Current EBITDA | $-1.2M |
| + RCM Uplift | +$701K |
| Pro Forma EBITDA | $-542K |
| Current Margin | -13.2% |
| Pro Forma Margin | -5.7% |
| WC Released (1x) | $362K |
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 | $-1.9M | $-1.2M | 0.00x | -100.0% |
| Base (11x exit) | 10.0x | 11.0x | $-1.9M | $-1.9M | 0.00x | -100.0% |
| Bull Case | 9.0x | 11.0x | $-1.7M | $-234K | 0.00x | -100.0% |
| Bull (12x exit) | 9.0x | 12.0x | $-1.7M | $-763K | 0.00x | -100.0% |
| Bear Case | 11.0x | 10.0x | $-2.1M | $-4.1M | 0.00x | -100.0% |
| Bear (11x exit) | 11.0x | 11.0x | $-2.1M | $-5.2M | 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 |
| High | Elevated distress probability | Model estimates 51.3% 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
- 2205 hospitals with 35-140 beds
- Same-state prioritization (n=7)
- Comp margins: P25=-15.9% / P50=-3.1% / P75=8.5%
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.