MADISON REGIONAL HEALTH SYSTEM
1. Target Overview & Investment Thesis
MADISON REGIONAL HEALTH SYSTEM is a 22-bed rural/critical access in LAKE, SD with $33.8M in net patient revenue and a -1.6% operating margin. The hospital serves a payer mix of 71.5% Medicare, 9.0% Medicaid, and 19.6% commercial.
Thesis: Turnaround. Our ML models identify $2.5M in annual EBITDA improvement potential from RCM optimization across 5 levers, lifting margin from -1.6% to 5.7% (+736bps).
| Net Revenue HCRIS | $33.8M |
| Current EBITDA COMPUTED | $-553K |
| Operating Margin COMPUTED | -1.6% |
| Occupancy HCRIS | 54.9% |
| Revenue / Bed COMPUTED | $1.5M |
| Net-to-Gross HCRIS | 52.3% |
| Distress Probability ML | 51.8% |
2. Market Context & Competitive Position
SD has 63 Medicare-certified hospitals with a median operating margin of -3.2%. The target's margin of -1.6% places it above the state median. Among 42 size-comparable peers (11-44 beds), the median margin is -1.9%. The target performs in line with or above peers.
3. RCM Performance Analysis — Comparable Hospitals
Comps selected by bed count (11-44), prioritizing same-state peers. 42 hospitals in the comp set.
| Hospital | State | Beds | Revenue | Margin |
|---|---|---|---|---|
| MADISON REGIONAL HEALTH SYSTEM (Target) | SD | 22 | $33.8M | -1.6% |
| SIOUX FALLS SPECIALTY HOSPITAL | SD | 33 | $138.8M | 31.7% |
| AVERA SACRED HEART HOSPITAL | SD | 42 | $123.1M | -1.9% |
| AVERA QUEEN OF PEACE | SD | 25 | $122.9M | -5.8% |
| MONUMENT HEALTH SPEARFISH HOSP | SD | 27 | $116.6M | 1.9% |
| SIOUXLAND SURGERY CENTER | SD | 38 | $105.7M | 40.1% |
| BLACK HILLS SURGICAL HOSPITAL | SD | 26 | $91.1M | 15.3% |
| HURON REGIONAL MEDICAL CENTER | SD | 25 | $49.4M | -5.9% |
| MONUMENT HEALTH STURGIS REGION | SD | 25 | $39.1M | -3.3% |
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: $2.5M (736bps margin improvement).
| Lever | Current | Target | EBITDA Impact | Margin | Ramp |
|---|---|---|---|---|---|
| Net Collection Rate | 93.5% | 97.0% | $709K | +210bp | 18mo |
| Cost to Collect | 4.5% | 2.5% | $675K | +200bp | 12mo |
| Denial Rate Reduction | 12.0% | 6.5% | $668K | +198bp | 12mo |
| A/R Days Reduction | 5200.0% | 3800.0% | $411K | +122bp | 9mo |
| Clean Claim Rate | 88.0% | 96.0% | $22K | +6bp | 6mo |
5. EBITDA Bridge
| Current EBITDA | $-553K |
| + RCM Uplift | +$2.5M |
| Pro Forma EBITDA | $1.9M |
| Current Margin | -1.6% |
| Pro Forma Margin | 5.7% |
| WC Released (1x) | $1.3M |
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 | $-851K | $21.2M | 0.00x | -100.0% |
| Base (11x exit) | 10.0x | 11.0x | $-851K | $23.0M | 0.00x | -100.0% |
| Bull Case | 9.0x | 11.0x | $-766K | $31.0M | 0.00x | -100.0% |
| Bull (12x exit) | 9.0x | 12.0x | $-766K | $33.6M | 0.00x | -100.0% |
| Bear Case | 11.0x | 10.0x | $-936K | $9.1M | 0.00x | -100.0% |
| Bear (11x exit) | 11.0x | 11.0x | $-936K | $9.7M | 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 | Heavy Medicare dependence | Medicare comprises 71.5% of days; rate updates may lag inflation. Mitigant: CDI/CMI lever directly increases Medicare reimbursement |
| High | Elevated distress probability | Model estimates 51.8% 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
- 42 hospitals with 11-44 beds
- Same-state prioritization (n=43)
- Comp margins: P25=-7.6% / P50=-1.9% / P75=8.9%
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.