AVERA FLANDREAU HOSPITAL
1. Target Overview & Investment Thesis
AVERA FLANDREAU HOSPITAL is a 18-bed rural/critical access in MOODY, SD with $10.7M in net patient revenue and a 13.8% operating margin. The hospital serves a payer mix of 61.3% Medicare, 3.3% Medicaid, and 35.4% commercial.
Thesis: Turnaround. Our ML models identify $796K in annual EBITDA improvement potential from RCM optimization across 5 levers, lifting margin from 13.8% to 21.2% (+741bps).
| Net Revenue HCRIS | $10.7M |
| Current EBITDA COMPUTED | $1.5M |
| Operating Margin COMPUTED | 13.8% |
| Occupancy HCRIS | 12.0% |
| Revenue / Bed COMPUTED | $597K |
| Net-to-Gross HCRIS | 50.2% |
| Distress Probability ML | 60.9% |
2. Market Context & Competitive Position
SD has 63 Medicare-certified hospitals with a median operating margin of -3.2%. The target's margin of 13.8% places it above the state median. Among 40 size-comparable peers (9-36 beds), the median margin is -1.6%. The target performs in line with or above peers.
3. RCM Performance Analysis — Comparable Hospitals
Comps selected by bed count (9-36), prioritizing same-state peers. 40 hospitals in the comp set.
| Hospital | State | Beds | Revenue | Margin |
|---|---|---|---|---|
| AVERA FLANDREAU HOSPITAL (Target) | SD | 18 | $10.7M | 13.8% |
| SIOUX FALLS SPECIALTY HOSPITAL | SD | 33 | $138.8M | 31.7% |
| AVERA QUEEN OF PEACE | SD | 25 | $122.9M | -5.8% |
| MONUMENT HEALTH SPEARFISH HOSP | SD | 27 | $116.6M | 1.9% |
| 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% |
| MADISON REGIONAL HEALTH SYSTEM | SD | 22 | $33.8M | -1.6% |
| SANFORD MEDICAL CENTER VERMILL | SD | 25 | $32.0M | 8.3% |
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: $796K (741bps margin improvement).
| Lever | Current | Target | EBITDA Impact | Margin | Ramp |
|---|---|---|---|---|---|
| Net Collection Rate | 93.5% | 97.0% | $226K | +210bp | 18mo |
| Denial Rate Reduction | 12.0% | 6.5% | $215K | +200bp | 12mo |
| Cost to Collect | 4.5% | 2.5% | $215K | +200bp | 12mo |
| A/R Days Reduction | 5200.0% | 3800.0% | $131K | +122bp | 9mo |
| Clean Claim Rate | 88.0% | 96.0% | $10K | +9bp | 6mo |
5. EBITDA Bridge
| Current EBITDA | $1.5M |
| + RCM Uplift | +$796K |
| Pro Forma EBITDA | $2.3M |
| Current Margin | 13.8% |
| Pro Forma Margin | 21.2% |
| WC Released (1x) | $412K |
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 | $2.3M | $17.7M | 7.78x | 50.7% |
| Base (11x exit) | 10.0x | 11.0x | $2.3M | $20.2M | 8.89x | 54.8% |
| Bull Case | 9.0x | 11.0x | $2.0M | $23.6M | 11.52x | 63.0% |
| Bull (12x exit) | 9.0x | 12.0x | $2.0M | $26.3M | 12.86x | 66.7% |
| Bear Case | 11.0x | 10.0x | $2.5M | $13.0M | 5.19x | 39.0% |
| Bear (11x exit) | 11.0x | 11.0x | $2.5M | $15.1M | 6.04x | 43.3% |
7. Key Risks & Mitigants
| Severity | Risk Factor | Mitigant |
|---|---|---|
| Medium | Heavy Medicare dependence | Medicare comprises 61.3% of days; rate updates may lag inflation. Mitigant: CDI/CMI lever directly increases Medicare reimbursement |
| Medium | Low occupancy | At 12.0%, 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 60.9% 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
- 40 hospitals with 9-36 beds
- Same-state prioritization (n=41)
- Comp margins: P25=-9.0% / P50=-1.6% / P75=8.6%
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.