Not-for-profit health systems need a new enterprise strategy

Based on findings of recent original research, the current financial performance of not-for-profit (NFP) health systems raises concerns over their long-term financial viability. The research findings underscore the need for NFP health system leaders to reconceptualize their organization as comprising six strategic business units (SBUs) and then manage each in terms of competitiveness.

Research findings identify NFP financial challenges

The research sought to quantify the operating performance of the 109 largest health systems (by number of beds) by documenting their most recent financials. Based on statistics, these health systems account for 62% of all inpatient beds in the United States. The research focused on operating financials, excluding investment income and non-recurring items such as the recent 340B settlement (where such figures were available). The following exhibit shows how health systems can be segmented into three types: Traditional NFP health systems, NFP payviders (health systems with a payer component) and for-profit health systems.

While the average operating margin for the 105 NFP health systems studied is 0.73%, the for-profits’ average margin is 14 times higher, at 10.34%. This variance is magnified at the entity level, as is apparent in the exhibit below.

Neither size nor net revenue per bed drives financial performance among traditional health systems, and payviders did not perform better than traditional health systems.^a HCA Healthcare alone earned more than all 105 NFP systems combined.

Health system segmentation into SBUs

For NFPs, addressing this challenge must begin with acknowledging their organizations’ structural complexity. Simply put, health systems are conglomerates. The first step to develop a strategy for a conglomerate is to identify its SBUs. Health systems have six SBUs (as shown in the exhibit below).

These SBUs differ operationally and financially, and each one presents a managerial challenge that is very different from the challenges presented by the others. Yet financial and operational reports are not customized to address those differences across SBUs, nor do they evaluate the health system as a conglomerate for resource allocation.

The payer UnitedHealthcare is the largest or nearly largest healthcare entity in terms of outpatient services (the third-largest ambulatory surgery center operator with 250), employed physicians, medication-based care (with the largest pharmacy benefit manager and numerous specialty pharmacies) and health plan ownership (with the largest Medicare Advantage membership), a large Medicaid plan and, in most cases, each state’s second-largest commercial payer. The fact that UnitedHealthcare does not own a single hospital sends a clear message of the relatively poor economics of owning assets in SBU 1 (emergent care) and SBU 2 (nonemergent inpatient care). (See the sidebar overview below of the strategy for SBUs 1-3 that the for-profits HCA Healthcare and Tenet Healthcare use to address this challenge [to come].)

SBU-specific tactics for NFP health systems

Following are key issues and recommended tactics for health system leaders to consider as they develop strategies to improve their performance at the SBU level.

1 Emergent medical care (from emergency department through inpatient care). This SBU is the genesis of a hospital-centric health system, yet it usually is unprofitable while demanding substantial ongoing capital investments. Until this SBU is financially self-sufficient, it will be a financial albatross for hospitals. Commercial rates should be increased appropriately for services that only hospitals perform (e.g., inpatient and, particularly, intensive care).

Payment alone will not fix this SBU. Instead, its scope starts with patients long before their emergent conditions occur (if they lack a medical home other than the ED) and ends 30+ days post-discharge. The best way to improve profitability is to minimize ED usage by patients whose encounters generate a negative contribution margin by providing an alternative that these patients prefer (such as a federally qualified health center located next to the ED, with evening and weekend hours for low-acuity visits) and by reducing demand by providing a medical home for patients with chronic conditions to substantially reduce ambulatory-care-sensitive ED visits and admissions.

Because virtually all inpatient payment is DRG-based, a health system’s survival requires dedicated efforts to accurately and completely document severity of patient conditions while reducing length of stay.

2 Non-emergent inpatient care. Surgical cases still drive inpatient profitability, so inpatient service-line growth remains essential. Nonsurgical units can earn direct margin and facilitate efforts to reduce length of stay (for emergent medical inpatient cases). Health systems should optimize their inpatient continuum of care to match Medicare’s structure, when possible. They should work to ensure the timely transfer of Medicare patients receiving general acute care to rehabilitation, long-term acute care, behavioral care and hospice care or post-acute care, as appropriate. By tightly integrating SBU 2 with SBU 1, health systems can ensure the efficient transfer of stabilized patients in emergent care units to non-emergent care units.

3 Outpatient facility services. These are elective services, so the patient has time to choose a provider after the order/procedure is determined. This SBU faces competition from large national firms that focus on one service (e.g., LabCorp) and regional entrepreneurial firms (also usually focused on one service). Competition also can come from the health system’s own medical staff from services they order or perform (e.g., imaging, surgery, infusion therapy), often with capital and management services from a national single-service firm (e.g., UnitedHealthcare’s Surgical Care Affiliates, Tenet Healthcare’s USPI and firms backed by private equity groups).

Health system disadvantages relative to their competitors tend to include:

• Substantially higher commercial contract rates (which encourage competitor usage) and higher Medicare rates for hospital-based locations
• A less well-developed patient service model
• A higher cost structure
• Less-effective revenue cycle processes

Traditional health systems should pursue the following tactics:

• Negotiate to comprehensively rebalance commercial rates, so outpatient services are priced at market levels and commercial rates for SBU 1 and SBU 2 are increased accordingly.^b
• Identify clinically relevant service distinctions and develop pricing/contractual methods to capitalize on them. Because CPT-based payment does not differentiate between low-end and high-end MRIs, for example, health systems should match market rates when the patient (and interpreting physician) only needs a low-quality scan, but they should contract accordingly for patients who need more expensive high-end services.
• Focus on improving the service offering and cost structure of each outpatient service — which can number more than 30 — given that each one likely faces focused competitors.
• Simplify the revenue cycle process for outpatient encounters and match collections policies of physician-owned and independent vendors (for example, calculate the patient responsibility per contract terms during pre-certification and collect it before the procedure), while leveraging new technologies such as robotics.
• Pursue joint ventures with proceduralists.
• Partner with a national firm to manage services such as physician therapy.

4 Employed physician enterprise. Among the six SBUs highlighted here, the employed physician enterprise poses a particularly significant challenge for health systems. As of January 2024, hospitals and health systems employed 55.1% of physicians, or about 357,500 physicians, with an average subsidy (loss) per physician of $291,000, totaling $104 billion in annual subsidy (loss).^c According to data from the Agency for Healthcare Research and Quality, there are 623,676 inpatient beds, so the average subsidy is $167,000 per inpatient bed.

If we apply this figure to the 109 largest health systems based on bed count, they subsidize their employed physician enterprises by $65 billion annually — or by 6% of total operating revenues.

Health systems employ physicians to support all of the other SBUs, so NFP health systems should match the appropriate employed physician practices by specialty to all six SBUs to determine the integrated financials by both SBU and service line, and they then should prioritize service lines for growth while exiting others. For example, the orthopedic service line should include the economics of SBUs 2, 3 and 4 for all related services.

For SBUs 3 and 4, health systems compete for proceduralists with two types of entities:

• Single-specialty market entrants that offer the flexibility and income of private practice with the capital and management capabilities of a large organization
• Payers such as UnitedHealthcare

Health systems should consider converting their employment model into structures similar to private-equity-backed arrangements (subject to regulatory constraints).

5 Medication-based management. Chronic conditions drive the majority of healthcare expenditures. Virtually every person with a chronic condition has a physician (medical specialist or primary care physician) who manages their care, and 50% or more of those providers are employed by NFP health systems. These entities typically have access to 340B, which can generate strategically significant savings for eligible hospitals and their patients, amounting to roughly 4% of total operating expenses, based on publicly available reports. (See sidebar below examining reported 340B savings for nine health systems. [to come])

Capturing 340B value has become more difficult over the past 18 months as many drug manufacturers have restricted hospitals from using large contract pharmacy networks, often limiting a hospital to only one pharmacy (and requiring that pharmacy to be located within 40 miles). As a result, until hospitals can operate their own specialty pharmacies and change dispensing patterns, they could lose 25% to 90% of historic 340B margins.

6 Risk-based entity, inclusive of direct-contracting capabilities. As self-insured enterprises, health systems have always borne the financial risk of their own employee health plan. “Best practices” include:

• Steerage to owned/preferred providers (via network design, pre-certification)
• Use of a nonpayer third-party administrator (rather than giving major payers more market power)
• Use of a transparent pharmacy benefit manager that manages for lower net cost, not maximum rebate, and facilitates 340B eligibility for high-cost members

Steerage is the primary reason for a health system to bear risk. Bearing risk on attributed lives in a PPO product means the health system pays for profitable elective care of its members when it is performed by competitors. Hence, the most attractive targets for risk-sharing are locally controlled employers (e.g., cities, counties and firms with local headquarters) where a tight-network product offers employers lower costs as the health system leverages items in SBUs 1-3.

The question is, “When should a health system take risk for other populations?” A payer will pay at a capitated rate only when it expects that capitation will be less expensive than fee-for-service utilization at contract rates. Commercial capitation is an unlikely option because most employees work for self-insured employers, where capitation between the payer and providers is problematic. (See the sidebar below describing a Medicare Advantage contracting strategy [to come].)

Pulling the conglomerate together

To illustrate how health system leaders can take a conglomerate view of their organization, in terms of SBUs, consider the case example shown in the exhibit below. The exhibit shows the margin for an actual 600-bed hospital by SBU, earning $22 million in operating income. Direct margin (before physician subsidy attribution) is based on disguised data. Once physician subsidies are attributed by SBU, health system leaders can focus on SBU-specific initiatives to improve overall financial performance.

5 key takeaways

Based on the analysis findings, leaders of NFP health systems should take the following actions:

• Use the SBU framework for assessing/managing their operations.
• Explore converting their physician employment model into alignment models similar to those of entities backed by private equity groups.
• Leverage 340B, the unique not-for-profit asset, and refocus their population health capabilities on medication management (while strengthening their charity care enrollment).
• Capitalize on their local brand for health plan initiatives.
• Educate the board, encouraging input, debate and support for non-traditional tactics.

Although the scope of this undertaking is vast and the challenges are daunting, health systems that do not act decisively may not survive. Moreover, mere survival is insufficient: Our nation depends on health systems to offer world-class healthcare while also addressing the issues faced by underinsured and underserved communities. 

Footnotes

a. Although some types of NFP health systems, such academic medical centers, inner-city hospitals and rural hospitals face unique and vital concerns (e.g., regarding Graduate Medical Education research), the added challenges posed by such concerns are beyond the scope of this article.
b. For each payer, for example, the health system would take the most recent 12 months of volume and contract rates to calculate current net revenue by SBU and type of services (e.g., totaling say $100 million, of which SBU 3 was $30 million). If SBU 3’s contract rates were cut by 33%, then that $10 million would be “rebalanced” to SBU 1 and SBU 2 (e.g., perhaps increasing the rates for observations and medical admissions, plus higher rates for delivery and neonatal care).
c. Physician Advocacy Institute, Updated report: Hospital and corporate acquisition of physician practices and physician employment 2019-2023, prepared by Avalere Health, April 2024; and Kaufman Hall, Physician Flash Report, January 2024.

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How two leading for-profit health systems have developed their strategic business units

Not for profit (NFP) health systems should take a lesson from the for-profit giants HCA Healthcare in Nashville, Tenn., and Tenet Healthcare in Dallas.

HCA Healthcare

With 183 hospitals and 148 ambulatory service centers (ASCs), among other components, HCA Healthcare concentrates its hospitals in markets where it has a leading share, thereby making its network structure self-reinforcing. HCA has exited numerous markets where it could not grow into a top position.

With respect to its strategic business units in the areas of emergent care, HCA has:

• Greatly expanded emergent medical care via freestanding emergency departments (EDs) and urgent care centers, improved throughput and implemented posting of real-time ED waiting time on billboards to attract patients
• Focused nonemergent inpatient care on “non-commodity” services, such as orthopedics, neuroscience, trauma, burns, rehabilitation and behavioral health
• Pursued rapid growth in outpatient services in “off-campus” facilities, spending more on new outpatient facilities than on new inpatient facilities
• Employed relatively few physicians but has the largest graduate medical education (GME) program in the United States, with 302 programs in 72 hospitals with 45 specialties, encompassing 5,185 residents and fellows

Tenet Healthcare

Tenet Healthcare has 60 hospitals, and its ambulatory division (mostly United Surgical Partners International) owns/manages 330 ambulatory surgery centers (ASCs), usually structured as joint ventures with surgeons. Based on EBITDA, Tenet is evolving into an ASC firm with some hospitals. So far, in 2024, Tenet has completed or announced the sale of nine hospitals for $4 billion (plus 15-year revenue cycle agreements). Earning a strong return-on-assets in ASCs and revenue cycle services is far easier than in hospitals.

Lessons from HCA and Tenet         

These two health systems offer 10 important lessons for NFP hospitals:

1. Manage each SBU to be profitable, with a positive cash flow.
2. Manage each geographic market as a distinct profit center.
3. Compete only in geographic markets where market share is high. A high market share strengthens the “network effect” across the continuum.
4. In a market where a first- or second-place market position is unlikely, exit the market so capital can be focused elsewhere.
5. Increase entry points for urgent/emergent care. By 2025, for every hospital, HCA will have one-free standing ED and two urgent care centers.
6. For acute medical and surgical care, maximize throughput (lower length of stay) and case mix index and reduce semi-fixed costs via new nursing models.
7. Focus on rigorously managing non-labor costs.
8. Prioritize inpatient resources on profitable service lines and optimize inpatient care settings (e.g., acute care, inpatient hospice, rehabilitation and long-term acute care) for care and payment. (HCA has pursued children’s hospitals over the past decade.)
9. Partner with proceduralists for ASCs rather than employing physicians.

1. Leverage GME as a source of new physicians and optimize hospital operations accordingly for GME.

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Keys to developing an effective MA strategy

The capitation arrangements pursued by most health systems typically involve Medicare Advantage (MA). Health systems suffer from a massive information disparity in risk-based arrangements with payers such as UnitedHealthcare that control the dollar flows and payments made to their own service providers (including pharmacy benefit managers, specialty pharmacies, ambulatory surgery centers and physicians). MA plans have a reputation among some health systems for treating fee-for-service providers poorly, with high rates of denials and failure to pay contract rates.

A long-term solution to this problem for health systems that have substantial “brand equity” might be to develop branded MA plans. For example, a health system with a strong cardiac care program could develop a special-needs MA plan for patients with diabetes or heart failure specifically targeting the 32% of patients who account for 50% of medical costs. In addition, the health system could seek to toughen its negotiations with all other MA plans. This overall strategy would limit national payers to representing national employers, individual/small group markets, and Medicaid.

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Health system profitability divergence between medical and procedural services

The financial performance of hospitals vary substantially between inpatient medical services, which are primarily but not entirely emergent services, and procedural, services, which are mostly non-emergent). This assertion is supported by the experience of the health system shown in the exhibit below, which shows disguised data for a tertiary facility with a “good payer mix.” Each inpatient day generated $900 in direct margin per inpatient day. Commercial patients drove 95% of the total direct inpatient margin. Among commercial patients, procedural cases were associated with a direct margin per patient day almost twice as large as that for medical cases ($4,900 versus $2,700).

Analysis of this situation shows that, after including associated fixed and allocated costs of $800 per day, only commercial patients for this health system were profitable. The exhibit reinforces the reality that Medicare cases generate a small direct margin per patient day. Meanwhile, Medicaid reimbursement varies by state but is always lower than Medicare.

Case example tertiary hospital inpatient profitability
per patient day strategic business unit (SBUs) and by payer

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Documented Value of 340B to Health Systems

The financial value of 340B to health systems is rarely presented in a public setting.  However, over the past decade, the dollar value of 340B has been documented for 8 health systems, which are shown in the exhibit.  This exhibit compares the dollar savings of 340B to each entity’s operating expenses, to develop a simplistic benchmark of 4% of operating expenses.

340B potential for a health system: Health systems with notable 340B programs ($ in millions)

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Appendix: Operating Income for all health systems analyzed

				Operating margin	Annualized
Rank	Health System	HQ State	Beds		Operating income	Net revenue	Period	Source; comments
Not-for-Profit Traditional Health Systems (100)			300,504	0.78%	$6,168	$786,143
1	CommonSpirit Health	IL	17,107	-4.0%	($1,390)	$34,510	FY23	Beckers Hospital, 4/5/24, excl non-recurring
2	Ascension Health	MO	16,103	0.1%	$23	$30,034	6 mo 12’23	Ascension Health, 2/24/24, excl non-recurring
3	Trinity Health	MI	14,706	-2.0%	($432)	$21,600	FY23	Beckers Hospital, 4/5/24
4	Advocate Health	NC	10,528	0.3%	$106	$30,440	9mo 9 ’23	Beckers Hospital, 12/27/23
5	Providence	WA	9,511	-4.2%	($1,200)	$28,700	CY23	Beckers Hospital, 3/8/24
6	AdventHealth	FL	8,041	6.4%	$1,044	$16,250	12mo 6 ’23	EMMA, 6/30/23, Beckers Hospital 2/20/24
7	Bon Secours Mercy Health	OH	6,053	-1.7%	($207)	$12,139	FY23	Beckers Hospital, 3/26/24; excl 340B settle
8	Northwell Health	NY	5,287	-0.3%	($46)	$16,400	Q3 2023	Beckers Hospital, 12/27/23
9	Banner Health	AZ	5,189	2.0%	$283	$14,100	FY23	Beckers Hospital, 3/21/24
10	Cleveland Clinic	OH	5,106	0.4%	$64	$14,500	CY2023	HealthcareDive, 3/1/24
11	Corewell Health	MI	4,689	1.4%	$203	$14,933	9mo 9 ’23	Beckers Hospital, 11/14/23
12	Mercy	MO	4,453	0.1%	$12	$8,000	FY23	Beckers Hospital, 12/27/23
13	SSM Health	MO	4,105	-0.6%	($59)	$10,500	FY23	Beckers Hospital, 3/22/24
14	Baylor Scott and White Health	TX	3,991	8.3%	$1,268	$15,200	6mo 12 ’23	Beckers Hospital, 2/16/24
15	RWJBarnabas Health	NJ	3,972	-1.0%	($86)	$8,587	FY23	RWJBarnabas Financials, 12/31/23
16	New York Presbyterian Healthcare System	NY	3,970	-0.4%	($38)	$8,508	CY22	Propublica
17	Intermountain Healthcare	UT	3,950	0.9%	$137	$16,100	FY23	Beckers Hospital, 3/21/24
18	Christus Health	TX	3,902	4.2%	$325	$7,800	FY23	Beckers Hospital, 12/27/23
19	Sutter Health	CA	3,543	2.0%	$320	$16,100	CY23	Beckers Hospital, 4/5/24
20	Memorial Hermann Healthcare System	TX	3,537	4.1%	$323	$7,870	FY23	EY Audit 2023
21	University of California Health	CA	3,427	0.7%	$129	$19,270	FY23	University of California, 2023
22	Ochsner Health System	LA	3,295	0.8%	$56	$7,017	6mo 6 ’23	Ochsner Health, 2023
23	Piedmont Healthcare	GA	3,257	9.5%	$434	$4,564	FY22	KPMG Audit 2022
24	UNC Health Care System	NC	3,185	5.4%	$333	$6,110	FY23	UNC Health, 2023
25	Jefferson Health	PA	3,181	-2.4%	($231)	$9,700	FY23	Beckers Hospital, 8/15/23
26	BJC Healthcare	MO	3,166	2.1%	$142	$6,900	CY23	Beckers Hospital, 3/8/24
27	New York City Health and Hospitals Corporation	NY	3,161	-0.8%	($81)	$10,531	FY23	New York City Health and Hospitals, 6/30/23
28	Hackensack Meridian Health	NJ	3,099	3.0%	$231	$7,825	FY23	Hackensack Meridian Health, 12/31/23
29	Texas Health Resources	TX	3,015	1.5%	$86	$5,670	FY22	KPMG Audit 2022
30	University of Pennsylvania Health System	PA	2,915	7.0%	$611	$8,700	FY23	PWC Audit 2023
31	Novant Health	NC	2,888	1.8%	$147	$8,295	FY23	EMMA, 4/5/24
32	Adventist Health	CA	2,786	-1.7%	($100)	$5,837	9mo 9 ’23	Adventist Health, 9/30/2023
33	Unitypoint Health	IA	2,761	-1.4%	($66)	$4,640	3mo 9 ’23	Beckers Hospital, 12/29/23
34	Mayo Clinic Health System	MN	2,758	6.0%	$1,084	$17,944	CY23	Beckers Hospital, 2/28/24
35	Mass General Brigham	MA	2,715	-0.3%	($48)	$18,800	FY23	Beckers Hospital, 12/8/23
36	Houston Methodist	TX	2,629	6.5%	$429	$6,569	9mo 9 ’22	Houston Methodist Financials 2022
37	University Hospitals	OH	2,588	-3.9%	($211)	$5,400	FY22	University Hospitals, 2022
38	Baptist Health South Florida	FL	2,530	0.1%	$4	$5,112	FY22	Deloitte Audit 2022
39	Indiana University Health	IN	2,483	4.0%	$343	$8,640	CY 23	IU Health, 2/22/24
40	Mount Sinai Health System	NY	2,452	5.9%	$217	$3,682	9 mo 9 ‘ 22	Mount Sinai Finanicals 2022
41	Orlando Health	FL	2,440	8.1%	$491	$6,100	FY23	Beckers Hospital, 2/7/24
42	Baptist Memorial Health Care Corporation	TN	2,398	-6.5%	($220)	$3,400	FY22	Deloitte Audit 2022
43	MedStar Health	MD	2,364	1.9%	$147	$7,700	12 mo 6’23	KPMG Audit, 6/1/23
44	WellStar Health System	GA	2,319	-1.9%	($107)	$5,759	6 mo 12 ’23	Financials; recurring rev & costs only
45	Johns Hopkins Health System	MD	2,316	0.5%	$46	$8,780	6mo 12 ’23	Johns Hopkins 12/31/23
46	Montefiore Medical Center	NY	2,308	1.2%	$94	$7,700	CY23	Beckers Hospital, 3/15/24
47	University of Maryland Medical System	MD	2,295	-0.2%	($12)	$5,058	9mo 3 ’23	EMMA, 3/31/23
48	Ohiohealth	OH	2,271	5.3%	$304	$5,741	FY23	Plante & Moran Audit 2023
49	Northwestern Medicine	IL	2,252	4.0%	$352	$8,700	FY23	Beckers Hospital, 12/27/23
50	Emory Healthcare	GA	2,215	-12.6%	($670)	$5,330	FY23	KPMG Audit 2023, p.17, 36 in FN
51	Yale New Haven Health System	CT	2,192	-3.8%	($245)	$6,449	6mo 3 ’23	EMMA, 3/31/23
52	Prisma Health	SC	2,175	1.1%	$67	$6,000	FY23	Beckers Hospital, 3/8/24
53	West Virginia University Health System	WV	2,163	2.5%	$108	$4,400	9mo 9 ’23	Beckers Hospital, 11/15/23
54	Beth Israel Lahey Health	MA	2,101	-1.7%	($131)	$7,700	FY23	Beckers Hospital, 3/8/24
55	Franciscan Missionaries of Our Lady Health System	LA	2,066	-2.5%	($83)	$3,313	FY22	KPMG Audit 2022
56	UF Health	FL	2,051	6.7%	$176	$2,613	FY22	UF Health, 6/30/22
57	Baptist Healthcare System	KY	1,980	-1.1%	($47)	$4,133	9mo 5 ’23	Beckers Hospital, 7/31/23
58	Cedars Sinai Health System	CA	1,978	2.0%	$143	$7,300	FY23	Beckers Hospital, 10/24/23
59	OSF Healthcare System	IL	1,955	0.0%	$1	$4,001	FY23	Beckers Hospital, 12/29/23
60	Sanford Health	SD	1,946	5.6%	$402	$7,200	CY23	Beckers Hospital, 3/8/24
61	Jackson Health System	FL	1,893	6.8%	$165	$2,440	FY22	Jackson Health 2022 Report
62	Northside Hospital	GA	1,810	2.1%	$121	$5,892	FY22	Deloitte Audit 2022
63	University of Colorado Health	CO	1,808	4.8%	$332	$6,945	FY23	Plante & Moran Audit 2023
64	Henry Ford Health	MI	1,774	1.0%	$80	$7,800	FY23	Beckers Hospital, 3/14/24
65	NYU Langone Health	NY	1,746	8.3%	$686	$8,300	FY23	Beckers Hospital, 1/24/24
66	McLaren Health Care Corporation	MI	1,736	1.3%	$85	$6,534	9mo 6 ’23	EMMA, 6/30/23
67	Catholic Health	NY	1,724	5.1%	$158	$3,100	FY22	Catholic Health Rpt 2022, Fitch Ratings 2022
68	Allina Health	MN	1,703	-6.8%	($353)	$5,200	FY23	Beckers Hospital, 3/8/24
69	Hospital Sisters Health System	IL	1,693	-2.3%	($67)	$2,860	FY22	Beckers Hospital, 10/26/22
70	Sharp Healthcare	CA	1,688	1.5%	$64	$4,154	FY23 9/30	Annual financials
71	Lehigh Valley Health Network	PA	1,672	0.2%	$10	$4,129	FY23	Lehigh Valley Health Network, 12/23
72	Ballad Health	TN	1,671	1.0%	$25	$2,476	6mo 12 ’23	Ballad Health, 12/31/23
73	Inova Health System	VA	1,666	1.5%	$79	$5,100	FY22	Inova, 2022
74	Lee Health	FL	1,663	2.1%	$60	$2,800	6mo 3 ’23	Beckers Hospital, 5/4/23
75	Baptist Health	AR	1,623	-0.3%	($5)	$1,900	FY22	FORVIS Audit 2022
76	Fairview Health Services	MN	1,623	-4.1%	($164)	$4,032	Q2 2023	Beckers Hospital, 9/6/23
77	Memorial Healthcare System	FL	1,617	2.9%	$86	$3,000	FY23	Beckers Hospital, 8/2/23
78	Hartford Healthcare	CT	1,605	0.1%	$5	$5,800	6 mo 3 ’23	Beckers Hospital, 8/17/23
79	Atlantic Health System	NJ	1,597	3.3%	$130	$3,933	9mo 9 ’23	Atlantic Health System, 2023
80	Norton Healthcare	KY	1,545	1.9%	$76	$4,000	FY23	Beckers Hospital, 3/14/24
81	Duke University Health System	NC	1,535	-3.1%	($152)	$4,837	FY23	KPMG Audit 2023
82	Franciscan Health	IN	1,495	-7.5%	($253)	$3,358	FY22	PWC Audit 2022
83	Saint Francis Health System	OK	1,457	10.5%	$217	$2,058	FY22	EY Audit 2022
84	HonorHealth	AZ	1,416	1.1%	$33	$3,100	FY23	Beckers Hospital, 3/28/24
85	ECU Health	NC	1,401	-2.0%	($46)	$2,300	FY22	Beckers Hospital, 1/26/23
86	NorthShore – Edward-Elmhurst Health	IL	1,397	-0.5%	($27)	$5,343	FY22	EY Audit 2022
87	Methodist Le Bonheur Healthcare	TN	1,352	-12.1%	($221)	$1,821	6mo 23	Beckers Hospital, 10/13/23
88	Avera Health	SD	1,343	-0.6%	($18)	$2,916	9mo 3 ’23	Beckers Hospital, 4/25/23
89	Virtua Health	NJ	1,338	7.0%	$179	$2,561	FY22	Grant Thornton Audit 2022
90	Multicare Health System	WA	1,307	-6.1%	($292)	$4,767	6mo 6 ’23	EMMA 6/30/23
91	ChristianaCare	DE	1,304	0.8%	$90	$11,491	FY23	PWC Audit 2023
92	LCMC Health System	LA	1,300	-3.8%	($92)	$2,447	CY22	LaPorte Audit 2022
93	Vanderbilt Health	TN	1,298	1.6%	$112	$7,200	Q1 2024	Beckers Hospital, 12/27/23
94	Premier Health	OH	1,289	-3.7%	($85)	$2,300	FY23	Beckers Hospital, 3/18/24
95	Methodist Health System	TX	1,276	5.6%	$124	$2,194	FY22	Grant Thornton Audit 2022
96	ProMedica	OH	1,274	-1.3%	($45)	$3,300	CY23	Beckers Hospital, 3/8/24
97	WMC Health	NY	1,266	1.7%	$34	$2,024	FY22	Grant Thornton Audit 2022
98	The Ohio State University Wexner Medical Center	OH	1,264	9.3%	$415	$4,444	FY23	KPMG Audit 2023
99	Froedtert and the Medical College of Wisconsin	WI	1,259	1.8%	$66	$3,604	FY23	Froedtert Health, Inc. 2023
100	Broward Health	FL	1,257	-15.0%	($423)	$2,826	Jan-May ’23	Broward Bd Presentation
Not-for-profit payviders			20,849	0.48%	$847	$177,052
101	Kaiser Permanente	CA	9,217	0.3%	$329	$100,847	FY23	Kaiser Permanente, 2/9/24
102	UPMC	PA	6,047	-0.7%	($198)	$27,700	CY23	Beckers Hospital, 2/28/24
103	Sentara Healthcare	VA	2,314	3.8%	$427	$11,138	FY22	KPMG Audit 2022
104	Highmark (Allegany Health)	PA	1,975	1.2%	$338	$27,100	CY23	Highmark, 3/18/24
105	Geisinger	PA	1,296	-0.5%	($49)	$10,267	CY23	Beckers Hospital, 4/5/24
For-profit health systems			66,037	10.34%	$11,605	$112,288
106	HCA Healthcare	TN	37,478	11.9%	$7,706	$64,968	CY23	HCA’s financial statements 1/30/24
107	Tenet Healthcare	TX	12,690	12.2%	$2,510	$20,548	CY23	Tenet’s 2/8/24 fin statements
108	Community Health Systems	TN	10,077	1.7%	$214	$12,490	CY23	Firm investor website, 2/28/24
109	Universal Health Services	PA	5,792	8.2%	$1,175	$14,282	CY23	Firm investor website, 2/28/24