On August 3, 2015, Community Health Systems, Inc. (NYSE: CYH) announced its intention to separate 38 hospitals and Quorum Health Resources, LLC, a hospital management and consulting business, via a tax-free spin-off. The transaction is expected to be completed in the first quarter of 2016. The spin company, to be named Quorum Health Corporation, will include a diversified portfolio of 38 hospitals with an aggregate of 3,635 licensed beds across 16 states. The hospitals that will comprise Quorum Health Corporation have strong market positions and are primarily located in cities or counties having populations of 50,000 or less. In 84 percent of these markets, the hospital is the sole provider of acute care hospital services. Quorum Health Corporation will also include Quorum Health Resources, which provides hospital management and consulting services to 150 non-affiliated hospitals across the United States, most of which are located in similar markets as Quorum Health Corporation’s sole provider hospitals. For 2014, Quorum Health Corp. generated revenue of approximately $2.1 billion and adjusted EBITDA of approximately $255 million.
Community Health Systems, originally founded in 1986, provides healthcare services through hospitals they own and operate in selected markets throughout the United States with top market concentration in FL, PA and TX. With the recent acquisition of Health Management Associates (HMA), CYH consists of 199 affiliated hospitals geographically diversified across 29 states with approximately 31,000 licensed beds. Following the acquisition of HMA (announced July 2013, completed January 2014) and Triad Hospitals, Inc. (2007), CYH is now the largest publicly traded hospital company in the nation measured by number of hospital facilities. The company generates revenues through general and specialized hospital healthcare services and other outpatient services to patients including general acute care, emergency room, general and specialty surgery, critical care, internal medicine, obstetrics, diagnostic, psychiatric and rehabilitation. Payer mix consists of 51% managed care, 25% Medicare, 11% Medicare and 13% from other payers (e.g. self-pay).
CYH has a long history of acquiring and turning around underperforming assets. The company typically acquires two to four hospitals each year, generally in rural markets where the facility is the primary provider of acute care services. Before acquiring HMA, CYH had acquired over 115 hospitals since 1997 and had more than doubled EBITDA, in aggregate, at these facilities versus trailing twelve months pre-acquisition. As the company moves into the second year of its HMA acquisition, operating results are expected to improve toward industry EBITDA margins and potentially expand the valuation of the underperforming asset. CYH reported 2014 EBITDA margin of 14.3%, versus 18% for industry leader Universal Health Services (NYSE: UHS). CYH intends to apply best practices, standardized systems and procedures to improve HMA’s operating performance, which deteriorated in 2013 with the latter reporting only 13% of EBITDA margin compared to approximately 16% in 2010, 2011 and 2012. As background, CYH improved Triad’s EBITDA margin from approximately 12% to 16%. Given the company’s $17.3 billion in net debt, the spin-off provides a means of de-leveraging and incremental cash generation.
Comparables for both Quorum Health Corporation and post-spin CYH are fairly limited and consist of large acute care and diversified hospital systems such as Lifepoint Health, Inc. (NASDAQ: LPNT), HCA Holdings, Inc. (NYSE: HCA), Tenet Healthcare Corp. (NYSE: THC), and United Health Services (NYSE: UHS). These companies trade at an average EV/TTM EBITDA multiple of 9.5x and an EV/TTM sales multiple of 1.4x, with UHS trading at premium multiples owing to its superior earnings profile. It should be noted, however, that post-spin Quorum Health Corporation, at 38 hospitals, will operate on a substantially reduced scale relative to its peers. The post-spin company’s reduced operating scale may result in increased volatility and potential vulnerability to State based funding cuts, Medicaid expansion decisions and other market based issues relative to its larger, more diversified peers. Accordingly, one can apply discounted multiples of 7.0x EV/EBITDA and 0.8x EV/revenues, generating an implied enterprise value ranging from $1,680 million to $1,785 million. The applied 7x EV/EBITDA multiple approximates that of Tenet’s June 2013 acquisition of Vanguard Health Systems (7x transaction value to EBITDA), which comprised 28 acute-care hospitals in urban and suburban markets.
Backing out revenues and EBITDA associated with the Quorum Health operations, the post-spin parent company generated $16.5 million in 2014 revenues and $2.5 billion in EBITDA. Applying average peer multiples respectively to 2014 EBITDA and revenues generates an implied enterprise value of between $23,609 million and $23,767 million for this business. Note that this analysis excludes any potential future EBITDA upside associated with continued operational improvements at HMA.
The above analysis generates a total implied enterprise value of $25,420 million for pre-spin CYH. Factoring in for $17,346 million in net debt and 118 million shares outstanding implies a fair value estimate of $68 per share for pre-spin CYH. This sum-of-the-parts-based fair value estimate implies 15% upside to CYH’s current share price of $58 at the time of this writing, suggesting that the transaction may unlock substantial incremental value.