Fitch Ratings has affirmed at 'AA' the following bonds issued by the
North Carolina Medial Care Commissions on behalf of Cone Health.
--$60,170,000 hospital revenue refunding bonds, series 2011A;
--$47,980,000 hospital revenue bonds, series 2011B;
--$47,500,000 hospital revenue bonds, series 2004A;
--$85,200,000 hospital revenue bonds, series 2001A and B.
Additionally, Fitch has affirmed the 'F1+' rating on the outstanding
variable rate debt issued by the North Carolina Medical Care Commission
on behalf of Cone Health.
--$47,980,000 hospital revenue bonds, series 2011B.
The Rating Outlook has been revised to Negative.
Unsecured general obligations of the Cone Health obligated group, which
includes Alamance Regional Medical Center (ARMC) following the November
2013 debt issuance. The obligated group represents approximately 86% of
the system's revenues and 94% of system assets with ARMC. Fitch reports
on the consolidated system. ARMC was included for five months of fiscal
KEY RATING DRIVERS
DECLINE IN OPERATING RESULTS: The Outlook revision to Negative reflects
the sharp decline in Cone Health's (Cone) operating profitability that
began in fiscal 2012 and worsened in fiscal 2013 (year ended Sept. 30;
unaudited, but in substantially final form) Due to a number of one-time
items, Cone expects to end fiscal 2013 (unaudited) with an operating
loss of $49.5 million (negative 4.3% operating margin), a weak 2.6%
operating EBITDA margin and net loss of $23.3 million.
IMPROVED PROFITABILITY IN 2014: The first quarter of fiscal 2014 ended
Dec. 31, 2013; however, has shown a significant improvement over the
prior year period with operating gain of $5.4 million. The system has
budgeted to produce a slim, but positive operating gain in fiscal 2014
and is implementing a long range plan that is intended to actually
exceed the budget.
DOMINANT MARKET POSITION: The system's market position is supported by a
broad placement of inpatient and outpatient service locations, enhanced
by the addition of ARMC, which should reduce outmigration to Durham and
Chapel Hill. The system's position is also supported by a large, loyal
referral base of employed and voluntary medical staff. An additional
positive is the October 2012 affiliation with Carolinas Health System
(CHS). Fitch views the strong North Carolina certificate of need program
as a further mitigant to competitive risk.
MODERATE LEVERAGE: Debt service coverage declined in fiscal 2013 to 2.1x
maximum annual debt service (MADS), but the system has very moderate
leverage with MADS representing 2.3% of revenues and debt to
capitalization of only 26%. Cone has now completed its large capital
improvement plan with no plans for additional issuance in the near to
intermediate term and has manageable ongoing capital needs. Coverage of
MADS improved to a much stronger 5.2x through the first quarter of 2014.
ADEQUATE LIQUIDITY: Cone maintains solid liquidity, which helps to
mitigate its weakened operating performance. DCOH was reported at 260.8
days through the end of the first quarter of 2014, and the system has
170.1% cash to debt on a consolidated basis including ARMC. The cushion
ratio was better than 30x even in fiscal 2013 and was most recently at
MARKED IMPROVEMENT EXPECTED: Fitch believes the deterioration in
profitability is due to one-time items and does not reflect a
fundamental change in operations. As such, Fitch expects Cone to
outperform its conservative 2014 budget (operating EBITDA near 8%), as
evidenced by strong first quarter results. However, failure to generate
profitability margins and debt service coverage consistent with
historical levels would likely produce negative rating pressure.
Cone Health is a nonprofit, integrated healthcare system headquartered
in Greensboro, North Carolina, operating four acute care and two
specialty hospitals, with total revenues of $1.1 billion in the fiscal
year ending Sept. 30, 2013. ARMC was merged into the obligated group
effective May 1, 2013 and is included in the consolidated system results
for five months of fiscal 2013. Cone Health entered into a 10-year
management agreement with Carolinas Health System, a large healthcare
system operating more than three dozen hospitals in North and South
Carolina. The top five key Cone Health leadership individuals are now
CHS employees. The benefits of the affiliation are estimated at
approximately $20 million on an annual basis and the affiliation is
viewed as a credit positive.
FINANCIAL PERFORMANCE REBOUNDING
Cone Health's financial performance declined in fiscal 2012, and
significantly worsened in fiscal 2013, which ended with an operating
loss of $49.5 million (-4.3%) and a very weak operating EBITDA margin of
2.6%, far below the budgeted operating gain of $27.6 million. The 2013
results contrasted sharply with the system's history of solid respective
operating and operaing EBITDA margins of approximately 4% and 10% in
the 2009 - 2011 period. The main drivers behind the poor 2013 results
included major issues with outsourced physician billing, increased labor
expenses related to the implementation of its EPIC electronic health
record, expenses related to the ARMC merger, as well as investment in
Triad Health Network (THN) -- its clinical integrated network.
Additional unbudgeted expenses included an increase in pension charges
of $5.5 million, higher than budgeted consulting and legal expenses
related to the ARMC merger, CHS affiliation and EPIC installation, and
$3.5 million of severance costs associated with reduction of
approximately 150 FTE positions. Cone Health replaced the professional
billing vendor in August 2013 with Alleviant (a Navigant subsidiary),
but experienced poor collection performance throughout the year and
incurred a significant write-off at year end.
The rating affirmation at 'AA' is supported by Fitch's expectation that
the steps taken by leadership to return the organization to a more
stable operating platform will demonstrate measurable results in fiscal
2014. A five-year long range financial plan has been formulated with the
aim of generating operating EBITDA margins of close to or better than
10%, only slightly lower than Fitch's 'AA' median of 11.8%. The plan
initiatives include a cost reduction plan of $30 million and $28 million
in revenue cycle improvements. The long-range plan includes a further
reduction of 100 FTE's in the current fiscal year.
Results for the first quarter of fiscal 2014 appear to support the
beginning of the turnaround. The consolidated system reported operating
income of $5.4 million, which translated to operating margin of 1.6% and
operating EBITDA margin of 8.6%.
DOMINANT MARKET POSITION
Cone Health commands a dominant market share in Guilford, Rockingham and
Alamance counties ranging between 60 - 70%. The merger with ARMC has the
potential of reducing the outmigration of patients in ARMC's market to
the tertiary providers in Durham and Chapel Hill. The system has a
highly integrated clinical network, Triad Health Network, with 844
physicians; of whom approximately 40% are employed and over a third in
primary care. Triad qualified as an ACO and is one of the largest ACO's
in the CMS's Shared savings program with 40,000 Medicare lives. The ACO
covers an additional 26,000 lives of Cone Health employees and other
Cone also maintains manageable debt levels, with MADS representing a low
2.3% of revenues and debt to capitalization of only 26%. Debt service
coverage declined in fiscal 2013 to 2.1x MADS, but coverage of actual
debt service as per Cone Health's Master Trust Indenture was a much
better 6.2x in fiscal 2013. Coverage of MADS improved considerably to a
much stronger 5.2x through the first quarter of 2014. Cone has now
completed its large capital improvement plan with no plans for
additional issuance in the near to intermediate term and has manageable
ongoing capital needs with 2014 capital plan equal to 115% of
In November 2013 Cone Health issued its Series 2013 bonds in the amount
of $130.2 million through the North Carolina Medical Care Commission as
a direct placement debt with BMO Harris Investments Corp and Bank of
America N.A. The bonds were used to retire the $42.9 million under the
system's line of credit, fund a construction account with $60 million
for use on two projects at ARMC - doubling of the ED capacity and
construction of a cancer center (both now close to being completed), and
to fund an escrow to repay the Alamance Extended Care Series 2007 bonds.
The bonds have annual principal payments starting in fiscal year 2014
through 2024 with an $88.8 million bullet due in 2024, which the system
plans to refinance prior to its maturity. The bonds are fixed rate
obligations through 2024 with an average interest rate of 2.815%.
Fitch's coverage calculation includes the bullet as per its stated
amortization between 2024 - 2045.
Cone's debt structure currently has approximately 40% of its debt in
fixed-rate mode and several bank commitments have been renegotiated with
extended renewal dates. The risk associated with the $88.8 million
bullet in 2024, as well other put, interest rate, and bank renewal risk
is adequately offset by strong liquidity position with 261 days cash on
hand and the system leadership's demonstrated ability to effectively
manage its debt and swap portfolio.
The affirmation of the 'F1+' short-term rating is based on the
availability of highly liquid securities to cover potential maximum
liquidity demands presented by Cone Health's outstanding series 2004A
weekly variable rate demand bonds (VRDBs) and the series 2011B bonds in
the window mode. Cone Health meets Fitch's criteria for assigning
short-term ratings based on internal liquidity, requiring coverage of
unremarketed puts of the maximum tender exposure of the self-liquidity
supported debt by a minimum of 1.25x based on Cone Health's cash and
highly liquid investments.
Cone Health has liquidation procedures in place detailing the process by
which internal funds would be liquidated to meet the tender obligations.
The 'F1+' rating for the 2011B bonds takes into account Cone Health's
sufficient unrestricted liquidity in addition to market access at its
rating level relative to the series 2011B bonds in the window mode,
which provides more flexibility to fund an unremarketed tender (180 days
beyond 30 day remarketing period).
Cone Health covenants to provide annual disclosure no later than 120
days after each fiscal year end and quarterly disclosure no later than
60 days after each quarter end to the Municipal Securities Rulemaking
Board's EMMA system.
Additional information is available at 'www.fitchratings.com'.
Applicable Criteria and Related Research:
--'Criteria for Assigning Short-Term Ratings Based on Internal
Liquidity'(June 13, 2013);
--'Nonprofit Hospitals and Health Systems Rating Criteria' (May 20,
--'Rating U.S. Municipal Short-Term Debt' (Nov. 27, 2012).
Nonprofit Hospitals and Health Systems Rating Criteria - Effective Aug.
12, 2011 to July 23, 2012
Rating U.S. Municipal Short-Term Debt - Effective Dec. 23, 2010 to Dec.
Rating U.S. Public Finance Short-Term Debt
ALL FITCH CREDIT RATINGS ARE SUBJECT TO CERTAIN LIMITATIONS AND
DISCLAIMERS. PLEASE READ THESE LIMITATIONS AND DISCLAIMERS BY FOLLOWING
THIS LINK: HTTP://FITCHRATINGS.COM/UNDERSTANDINGCREDITRATINGS.
AVAILABLE ON THE AGENCY'S PUBLIC WEBSITE 'WWW.FITCHRATINGS.COM'.
PUBLISHED RATINGS, CRITERIA AND METHODOLOGIES ARE AVAILABLE FROM THIS
SITE AT ALL TIMES. FITCH'S CODE OF CONDUCT, CONFIDENTIALITY, CONFLICTS
OF INTEREST, AFFILIATE FIREWALL, COMPLIANCE AND OTHER RELEVANT POLICIES
AND PROCEDURES ARE ALSO AVAILABLE FROM THE 'CODE OF CONDUCT' SECTION OF
THIS SITE. FITCH MAY HAVE PROVIDED ANOTHER PERMISSIBLE SERVICE TO THE
RATED ENTITY OR ITS RELATED THIRD PARTIES. DETAILS OF THIS SERVICE FOR
RATINGS FOR WHICH THE LEAD ANALYST IS BASED IN AN EU-REGISTERED ENTITY
CAN BE FOUND ON THE ENTITY SUMMARY PAGE FOR THIS ISSUER ON THE FITCH
[ Back To NFVZone's Homepage ]