HOSP. METROPOLITANO DE SAN GERMAN
1. Target Overview & Investment Thesis
HOSP. METROPOLITANO DE SAN GERMAN is a 63-bed safety-net/medicaid heavy in SAN GERMAN, PR with $28.5M in net patient revenue and a -8.2% operating margin. The hospital serves a payer mix of 7.0% Medicare, 31.5% Medicaid, and 61.6% commercial.
Thesis: Turnaround. Our ML models identify $2.1M in annual EBITDA improvement potential from RCM optimization across 5 levers, lifting margin from -8.2% to -0.8% (+736bps).
| Net Revenue HCRIS | $28.5M |
| Current EBITDA COMPUTED | $-2.3M |
| Operating Margin COMPUTED | -8.2% |
| Occupancy HCRIS | 61.1% |
| Revenue / Bed COMPUTED | $453K |
| Net-to-Gross HCRIS | 63.7% |
| Distress Probability ML | 56.2% |
2. Market Context & Competitive Position
PR has 61 Medicare-certified hospitals with a median operating margin of -8.8%. The target's margin of -8.2% places it above the state median. Among 23 size-comparable peers (32-126 beds), the median margin is -17.0%. The target performs in line with or above peers.
3. RCM Performance Analysis — Comparable Hospitals
Comps selected by bed count (32-126), prioritizing same-state peers. 23 hospitals in the comp set.
| Hospital | State | Beds | Revenue | Margin |
|---|---|---|---|---|
| HOSP. METROPOLITANO DE SAN GER (Target) | PR | 63 | $28.5M | -8.2% |
| ADMIN DE SERVICIOS MEDICOS DE | PR | 65 | $179.7M | -50.0% |
| HOSPITAL MENONITA HUMACAO | PR | 73 | $53.1M | 31.3% |
| METRO MAYAGUEZ | PR | 122 | $50.5M | -2.9% |
| HOSPITAL DR. SUSONI | PR | 119 | $46.5M | -4.9% |
| HOSPITAL DR. PILA | PR | 115 | $43.3M | -5.7% |
| HOSPITAL WILMA N VAZQUEZ | PR | 100 | $37.6M | 5.6% |
| DOCTORS CENTER HOSPITAL CAROLI | PR | 109 | $35.5M | -4.3% |
| HOSPITAL METRO HATO REY INC. | PR | 84 | $34.2M | -18.8% |
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: $2.1M (736bps margin improvement).
| Lever | Current | Target | EBITDA Impact | Margin | Ramp |
|---|---|---|---|---|---|
| Net Collection Rate | 93.5% | 97.0% | $599K | +210bp | 18mo |
| Cost to Collect | 4.5% | 2.5% | $570K | +200bp | 12mo |
| Denial Rate Reduction | 12.0% | 6.5% | $564K | +198bp | 12mo |
| A/R Days Reduction | 5200.0% | 3800.0% | $347K | +122bp | 9mo |
| Clean Claim Rate | 88.0% | 96.0% | $18K | +6bp | 6mo |
5. EBITDA Bridge
| Current EBITDA | $-2.3M |
| + RCM Uplift | +$2.1M |
| Pro Forma EBITDA | $-241K |
| Current Margin | -8.2% |
| Pro Forma Margin | -0.8% |
| WC Released (1x) | $1.1M |
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 | $-3.6M | $5.6M | 0.00x | -100.0% |
| Base (11x exit) | 10.0x | 11.0x | $-3.6M | $4.9M | 0.00x | -100.0% |
| Bull Case | 9.0x | 11.0x | $-3.2M | $10.7M | 0.00x | -100.0% |
| Bull (12x exit) | 9.0x | 12.0x | $-3.2M | $10.7M | 0.00x | -100.0% |
| Bear Case | 11.0x | 10.0x | $-4.0M | $-3.8M | 0.00x | -100.0% |
| Bear (11x exit) | 11.0x | 11.0x | $-4.0M | $-5.4M | 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 | Elevated Medicaid exposure (31.5%) | Medicaid reimburses below cost in most states. Mitigant: denial reduction lever has highest impact on Medicaid claims |
| High | Elevated distress probability | Model estimates 56.2% 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
- 23 hospitals with 32-126 beds
- Same-state prioritization (n=24)
- Comp margins: P25=-36.6% / P50=-17.0% / P75=-2.1%
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.