Like relatives outside a patient's sickroom, some hospital experts have once again started hoping for the best.
The industry's vital signs remain rather weak. Hospitals continue to struggle with mounting shortages of doctors, nurses and -- perhaps most importantly -- insured patients who actually pay their bills. As a result, they have wound up sharing some of their profits with available physicians while getting sued for allegedly sharing too little with the nurses who help those doctors out. Meanwhile, they have found no real cure for bad debts from the uninsured and could wait years before the best prospects -- like health care credit cards and state-mandated health insurance -- actually take off.
Yet, despite everything, some hospital analysts have been warming up to hospital giant
"They talk about easier comps," or year-over-year comparisons, says Sheryl Skolnick, senior vice president of CRT Capital Group. "But that doesn't make me feel like I'm part of a growing industry. It just makes me feel like it's less worse than the past year or two. ... And I still don't see where the change in volumes is going to come from."
Thus, Skolnick has found herself unable to recommend a single hospital stock. In contrast, Wachovia analyst William Bonello views HCA, at least, as a wonderful bargain right now. Bonello believes the company can muster some volume growth over the next several years that will, in turn, translate into big gains on the bottom line.
"HCA is trading at a discount to other hospitals, despite the fact that its operating metrics have been comparable to many of its peers, and its returns have been the best in the group," writes Bonello, whose firm helped with a recent securities offering by the big hospital chain. "We think that the current stock price reflects a fairly pessimistic investor sentiment. Thus, we believe small improvements in admissions or margins, or modest EPS (earnings-per-share) upside, could be a catalyst for multiple expansion."
For now, however, the stock continues to languish. It inched up just 13 cents to $43.30 during a big market surge on Wednesday, leaving it near the bottom of its 52-week range of $42.02 to $58.60 a share.
Perks for Physicians
Even HCA, with all of its muscle power, has been unable to escape negative industry trends.
Just take a look at the company's latest quarterly results. Volume took a hit as available physicians, lured by competing hospitals, sent their patients elsewhere in Florida and Virginia.
Meanwhile, other hospital chains like
and HMA have taken expensive steps to keep their own doctors loyal. Triad has laid out plans to offer physicians stock in virtually all of its hospitals,
has reported. Meanwhile, Skolnick says, HMA has put some doctors on the payroll and made them hospital employees.
Skolnick points to HMA's recent acquisition of the Cleveland Clinic hospital in Florida -- which came with 400 doctors -- as evidence of this strategy. She then goes on to question whether the company really got its money's worth or, perhaps, overpaid for yet another hospital instead.
"The implication for the discussion of valuation is that, unlike previous acquisitions, HMA is buying more than just the bricks, land and equipment in this case -- and that there is an implicit value in having 400 employed physicians," Skolnick wrote earlier this month. "But are they worth $1 million per bed, $900,000 per bed -- i.e., the premium over prices paid by others? We find that hard to justify."
At the same time, however, Skolnick understands that hospitals must seek new ways to attract doctors who are in increasingly short supply.
"You have to find some way to convince the doctors to love you -- and you've got to do it legally; that's a challenge," she says. So "these things are certainly being looked at."
Nurses in Need?
Meanwhile, nurses have shown no real love for HCA lately.
Rather, they have banded together to sue some of the company's hospitals for allegedly underpaying them. In multiple class-action lawsuits filed earlier this week, nurses accuse hospitals in major cities like San Antonio -- where HCA operates four hospitals -- of colluding on nurse salaries and depriving them of literally hundreds of millions of dollars in lost wages as a result.
HCA spokesman Jeff Prescott claims the allegations were drummed up in "frivolous, money-wasting lawsuits" by a union that's trying to stir up publicity in areas where it hopes to increase membership. But Peter Young, a business consultant at HealthCare Strategic Issues, sees evidence of possible labor shortcuts in a separate HCA market where nurses are reportedly planning to strike.
Young focuses in particular on labor costs at Los Robles Hospital, one of three HCA-owned hospitals in southern California faced with possible strikes. There, he says, hospital man hours per patient admission total just 107 -- almost 30% less than the 151 statewide average. Moreover, he sees similar patterns elsewhere within the HCA system.
"Both in Florida and California, HCA consistently has the lowest man hours per patient admission of any hospital operator," Young claims. Thus, "to our Wall Street friends, we suggest a substantial portion of HCA's net patient income is derived from seemingly overly aggressive labor savings practices that are not likely to be sustainable in the current business environment."
Boom or Bust?
Moreover, as it expands, HCA will need to lure even more nurses.
HCA is poised to open hospitals in four major cities -- including San Antonio -- over the next couple of years, Bonello notes. In addition, he says, the company is in the process of adding eight to 10 new ambulatory surgery centers right now.
Bonello welcomes the growth opportunities that may result.
"The older baby boomers are now in their late 50s," he points out. "As a result, the population growth in the 65-plus cohort should accelerate even more by the end of this decade. This should cause admissions and adjusted admissions to grow at an accelerating pace, since older people tend to utilize more care."
But Skolnick, for one, has grown weary of the familiar baby-boomer arguments offered up by hospital bulls. Quite simply, with Medicare strained and uninsured numbers growing, Skolnick wonders how hospitals will get paid for the services they provide.
To be fair, some relief -- particularly from the uninsured and underinsured -- could be on the way. Earlier this month, the
Nashville Business Journal
reported, rural hospital operator
revealed that it has teamed up with USBank to offer a credit card program that provides discounts and financing to the uninsured. Tenet is testing a similar venture with
, which operates a bank that provides financing to patients with "consumer-driven" health plans that can require big out-of-pocket payments.
Skolnick sees some merit in such arrangements.
"Even if 50% of the people with these credit cards don't pay, that still leaves 50% who are paying something who didn't pay before," she says. "That's a meaningful percentage. (So) it can help -- immediately."
Still, Skolnick believes, state-mandated insurance programs -- like one being adopted in Massachusetts -- could help even more. However, she feels, hospital investors need to exercise some patience in the meantime.
"That's one thing that, over time, may help the hospitals," she says. "But it's not a quick fix. It's not going to help them right away."