Trends in U.S. health care bankruptcy: a 10-year retrospective

Introduction

The past decade has proven extremely challenging for healthcare organizations operating in the United States (U.S.). Regulatory challenges, reimbursement changes, labor shortages, and the coronavirus disease 2019 (COVID-19) pandemic have all negatively impacted financial performance in the healthcare sector (1). Over 80 healthcare organizations filed for bankruptcy protection in 2023 alone, including hospitals, pharmaceutical companies, staffing firms, and senior living facilities (2). While most U.S. industries report a reduced number of bankruptcy filings since 2010, the healthcare sector has seen an increase in filings of over 300% (3). Healthcare spending accounted for approximately 17% of the gross domestic product of the U.S. economy in 2022 (4), so instability in the health sector is a concerning indicator for the overall economy.

Healthcare organizations are under pressure to do more with less. Value-based purchasing models require health care delivery organizations to meet certain quality standards or face reduced reimbursements (5). The U.S. has a significant number of uninsured citizens who require access to healthcare, and many organizations are challenged to provide care to these individuals while maintaining financial solvency (6). The COVID-19 pandemic upended the industry and eventually led to a huge labor shortage and increase in labor costs (7). Private equity groups have invested over $750 billion in healthcare companies ranging from physician groups to research and development firms since 2013, and this has significantly impacted the way healthcare organizations operate and access capital (8). Finally, technology companies have emerged as competitors to traditional healthcare firms offering operational efficiencies and patient facing technologies (9). These are just a few of the factors contributing to the financial challenges faced by U.S. healthcare organizations over the past decade.

Bankruptcy is the last resort for organizations facing financial distress. In the U.S., organizations have the option of filing Chapter 11 bankruptcy which allows for restructuring of debt and continued operation, or if the organization is in economic distress, Chapter 7 is an option in which the business is liquidated and closed (10). Although some organizations successfully emerge from bankruptcy and reorganize their operations, it often results in business failure. It is an expensive strategy which can cost millions of dollars to creditors and require years of operation under the supervision of the federal court system if successful.

While research has been conducted on hospital bankruptcy and organizational performance (1,11,12), no work has assessed the impact of bankruptcy on the entirety of the U.S. health system. This paper explores trends in bankruptcy filings among all U.S. healthcare organizations between 2013 and 2023 using data obtained directly from the U.S. Court System. Unlike prior studies, the bankruptcy cases analyzed will not be limited to a particular organizational type (e.g., hospital) or size. We will attempt to answer the following questions: (I) How many health care organizations are filing for bankruptcy? (II) What percentage are opting for a reorganization strategy vs. liquidation? (III) Does the size of the organization impact the success of its reorganization and ability to continue operations?

Bankruptcy in the U.S.

Bankruptcy filing rates for healthcare organizations are increasing at a higher rate than firms in other sectors of the U.S. economy (3). Most research on bankruptcy in healthcare organizations focuses specifically on hospitals (1,11,12). A deeper understanding of the U.S. bankruptcy system and the way all U.S. organizations seek financial relief from that system is important for organizational leaders, policymakers, and scholars.

There are typically two options for an organization seeking bankruptcy relief in the U.S.—Chapter 11 or Chapter 7. If a firm is in financial distress, the firm can file under Chapter 11 and formulate a reorganization plan that rearranges its financial obligations with an eye toward exiting Chapter 11 and continuing operations. The plan normally will provide for a discharge of pre-bankruptcy unsecured obligations and obligate the firm to pay such obligations under terms of the plan going forward. Secured obligations will normally be paid under pre-bankruptcy terms, as agreed to by the particular creditor or under the plan as approved by the bankruptcy court. Under this option, Chapter 11 provides a framework for the firm to work through its financial distress. It is a legal tool designed to rescue the firm.

The second option applies to firms that are in economic distress and not financially viable on an ongoing basis. Chapter 7 bankruptcy relief provides a legal tool to liquidate the assets of the firm and provide a return to creditors. The bankruptcy process avoids the piecemeal liquidation and collection efforts of individual creditors of firm, which normally negatively impacts the value of assets and return for the creditor group as a whole. Under Chapter 7, the firm is not rescued; it does not receive a discharge of pre-bankruptcy obligations and it ceases to operate.

Although there are two typical options for bankruptcy relief for organizations, determining whether the bankruptcy is successful is more complex. Bankruptcy success can be viewed as a continuum. On one end of the continuum, if under Chapter 11 a firm emerges with a reorganization plan and continues to operate, the bankruptcy can be viewed as success. The firm has been rescued. At the other end of the continuum, if under Chapter 7 the firm liquidates and ceases to operate, that can be viewed as an unsuccessful bankruptcy. The firm was not rescued.

However, there are a panoply of outcomes that can occur along the continuum between the two typical outcomes which can, depending on a particular case, be considered a success or unsuccessful.

The range of outcomes is rooted in Chapter 11’s design to be a flexible legal tool and to foster negotiation among the debtor firm, creditors and other stakeholders. The Bankruptcy Code provides default legal rules that apply if parties cannot negotiate an acceptable outcome, but if agreement can be reached that typically will be favored and embraced under bankruptcy law. That flexibility and negotiation can lead to outcomes that lie in the middle of the continuum, which may be considered a success or unsuccessful. Several examples can help illuminate the nuanced determination of success or unsuccessful.

First, assume a healthcare organization files for Chapter 11. As the case proceeds, the parties negotiate and work out agreed terms. If all parties agree, the case may be dismissed out of bankruptcy court and the parties operate under those agreed terms. Thus, there is no need to complete a Chapter 11 case with a reorganization plan. This type of outcome, a dismissal, may be a successful Chapter 11. The organization emerges from bankruptcy with its obligations rearranged and it continues to operate. Thus, it has been rescued under Chapter 11 and viewed as a success.

Secondly, assume a healthcare organization files for Chapter 11. As the case proceeds some negotiations are fruitful with creditors and agreed terms are reached, but not with all parties. The organization may identify some assets or parts of its business it can liquidate or sell, i.e., are not necessary going forward for the organization. It can sell assets or parts of its business in the Chapter 11 case. Then, the organization may be able to dismiss the case and continue to operate with its agreed to terms with creditors, after disposing of assets or parts of its business not necessary to continued operations. The organization has been rescued, at least in part, under Chapter 11, and is therefore considered a success at least in part.

Thirdly, assume a healthcare organization files for Chapter 11. During the case, the organization may determine it cannot successfully reorganize; however, it has assets and business operations that have an ongoing value. In Chapter 11, the organization can sell the assets and/or business as whole or in a series of sales. Then the firm can use those returns to pay creditors and then dismiss the case. In this instance, the dismissal may be viewed as unsuccessful as there was no rescue of the organization.

A great number of the cases included in the study lie in the middle of the continuum. The cases may be a success, a success at least in part, or unsuccessful. Without a detailed case analysis, it is difficult to ascertain whether certain cases are a success or not. However, data from the U.S. courts can provide a broad understanding of the number of organizations filing bankruptcy with the hopes of successful reorganization.

Bankruptcy in healthcare organizations

Bankruptcy and factors contributing to bankruptcy have been a topic of interest in the financial and accounting research for decades. Much of this work has focused on firms outside of the healthcare sector and has produced statistical models and artificial intelligence to generate predictive models of organizational failure or bankruptcy based on financial ratios (13-15). The Altman Z-score model is one of the most recognized predictive models of bankruptcy filing. This model uses a weighted combination of financial ratios (e.g., working capital/total assets; retained earnings/total assets; earnings before interest and taxes/total assets; equity/book value of total debts; sales/total assets) to predict organizational filings (16). Researchers have adapted this model to leverage its predictive capabilities in healthcare organizations; however, results of its usefulness in the healthcare setting are mixed and largely focused on healthcare delivery organizations including acute care hospitals, academic medical centers, rural hospitals, and nursing homes (17-21). Recently, researchers have employed artificial intelligence models to predict insolvency in the hospital sector, and such efforts will likely continue (11).

Although financial distress ultimately pushes organizations into bankruptcy, researchers have identified both internal and external factors contributing to financial insolvency and ultimately bankruptcy in hospitals. Internally, poor management—both operational and financial, aging facilities, low occupancy rates, quality problems, physician issues, and fraud allegations contribute to financial distress in hospitals. External factors contributing to hospital bankruptcy include reimbursement issues including a high percentage of government payers, market competition, demographic changes, and external physician politics (1,12,22-24). Over half of hospitals and health systems that seek bankruptcy protection are unsuccessful and cease operations, but larger hospitals that are affiliated with systems have a greater likelihood of successful reorganization (1,12). For-profit hospitals and those with lower cash flow are less likely to successfully emerge from bankruptcy (23).

Scant empirical research exists on bankruptcy among other U.S. healthcare organizations. Researchers have tested Altman’s Z-score on pharmaceutical firms in Russia, India, and Pakistan (25-27). However, this has not been applied recently in a U.S. setting. Most of the literature on bankruptcy in U.S. Pharma is related to Purdue Pharma and other companies facing large payouts from lawsuits stemming from the opioid crisis. These case studies delve into the ethics of such filings, but they do not attempt to explore factors contributing to the filings outside of massive legal settlements (28,29). Likewise, empirical research on bankruptcy filings by physician groups and staffing organizations is unavailable. However, researchers speculate that an uptick in such filings is fueled by the COVID-19 pandemic and private equity investment (30).

Researchers have attempted to create predictive models of bankruptcy filing in the nursing home industry (19,31) and identify factors contributing to financial distress and bankruptcy filing. Factors contributing to financial distress include for-profit status, chain affiliation, wage rates, payer-mix, and type of residents (31). Management factors including administrative costs and strategic decision making are also related to bankruptcy filing status (32). However, studies are limited to individual states, so a holistic view of bankruptcy in the nursing home industries is unavailable.

Most existent research on bankruptcies in healthcare organizations is focused on hospitals and health systems; however, these organizations only represent a small portion of bankruptcy filings in the healthcare sector. Only 48 hospitals and health systems filed for bankruptcy between 2007 and 2019 (1), which is a fraction of overall healthcare organization filings. The goal of most hospital bankruptcies is to continue operating as hospital closure has detrimental repercussions to the community (33). While researchers are getting a handle on factors contributing to hospital/health system bankruptcies, much remains unknown about other organizations filing in this sector of the economy including whether or not most of these organizations intend to keep operating and how successful their bankruptcy filings ultimately are. We present this article in accordance with the STROBE reporting checklist (available at https://jhmhp.amegroups.com/article/view/10.21037/jhmhp-24-78/rc).

Methods

Data sources

The sample used in this study is comprised of all healthcare bankruptcies filed in U.S. Bankruptcy Courts from 2012 to 2023. The original dataset provided 15,981 healthcare bankruptcies, from which 4,889 observations had bankruptcies closed during the years 2012–2023. These years were chosen for analysis because they are the most recent periods in which data were available. Additionally, these years are sufficiently removed from the 2005 bankruptcy reform which resulted in distorted filing rates generally and it is beyond the immediate impact of the 2008 recession. All data are from an Integrated Data Base (IDB) created by the Federal Judicial Center (FJC), an independent governmental agency. The FJC receives raw filing data directly from the Administrative Office of the U.S. Courts (AOUSC), the primary source of filing data. The FJC processes the raw filing data into a longitudinal database, the IDB, which is publicly available (34). The FJC’s IDB includes all bankruptcy filings. The sample in this study was collected from the full IDB and comprises of only those bankruptcies reported in the IDB as a healthcare business, i.e., a healthcare bankruptcy.

Dependent variables

The dependent variable is the Final Disposition of the healthcare bankruptcy categorized as successful, unsuccessful, and unknown. Successful bankruptcies are the Chapter 11 filings that are completed during the study period without converting to Chapter 7. This indicates that the filing organization has reorganized and continues operating. Unsuccessful bankruptcies are the filings that end in Chapter 7 during out study period. This indicates the organization liquidated assets and no longer operates. An unknown outcome indicates a filing organization exits the bankruptcy system without closing the bankruptcy. This might mean that they reached a resolution with creditors, or it might mean they were dismissed from bankruptcy. For the purposes of this study, we did not analyze the ‘not available’ bankruptcies.

Independent variables

The independent variables are the year of closing, size of organization’s assets, size of organization’s liabilities, chapter of filing, and chapter of closing. The IDB database reports each variable for healthcare bankruptcy in the sample. In an effort to find a proxy for organizational size, we sorted both the size of organizational assets and liabilities into groups representing small, medium, and larger organizations. The size of the organization’s assets was operationalized with three categories: $0 to $100,000, $100,001 to $1,000,000, and greater than $1,000,000. Similarly, the size of the organization’s liabilities was also operationalized with three categories: $0 to $1,000,000, $1,000,001 to $10,000,000, and greater than $10,000,000. The assets and liabilities categories were chosen to estimate approximately one-third of the sample in each group. Finally, we included a variable representing the number of years between bankruptcy filing and closing.

Control variable

The analysis also included a control variable for year of closing to account for temporal changes that may be associated with bankruptcies of healthcare organizations.

Statistical analysis

Univariate statistics were used to describe the sample bankruptcies and bivariate analyses were used to see if there are statistically significant differences between the final dispositions of the healthcare bankruptcy. Our analysis used a multinomial regression model to examine the relationships between the independent variables and bankruptcy disposition. Results are reported as average marginal effects, or marginal effects calculated at the actual value of the covariates.

Results

Sample descriptives

A total of 4,889 bankruptcy-year observations were included in the study, consisting of 837 (17.12%) successful bankruptcies, 125 (2.56%) unsuccessful bankruptcies, and 3,927 (80.32%) bankruptcies of unknown status. Figure 1 presents the trends in bankruptcies by closing status between 2012 and 2023. The proportion of successful bankruptcies consistently declined between 2012 and 2023, starting at 18.18% in 2012 and declining to 0% in 2023. Bankruptcies of unknown status increased approximately 20 points between 2012 and 2023, from 63.6% in 2012 to 87.4% in 2023. Unsuccessful bankruptcies hit a high in 2013 at 37.8% and steadily declined to 12.57% in 2023. Figure 2 presents the percentage of successful, unsuccessful, and unknown bankruptcies by asset class, whereas Figure 3 presents the percentage of successful, unsuccessful, and unknown bankruptcies by liabilities class.

Figure 1 Percentage of successful, unsuccessful, and unknown bankruptcies by year: 2012–2023, n=4,889.

Figure 2 Percentages of successful, unsuccessful, and unknown bankruptcies by assets. M, million.

Figure 3 Percentages of successful, unsuccessful, and unknown bankruptcies by liabilities. M, million.

Table 1 presents the descriptive statistics and bivariate results for the sample of healthcare organization bankruptcies. Forty-four percent of the healthcare organizations had assets under $100,000 (low), 27.76% had assets between $100,000 and $1,000,000 (medium), and 28.23% had assets over $1,000,000 (high). Approximately 49% of the organizations had liabilities in the low category of $0 to $1,000,000, 31.93% of the organizations had liabilities in the medium category of $1,000,001 to $10,000,000, and 18.92% had liabilities in the high category of over $10,000,000.

There are statistically significant differences among the bankruptcy dispositions in the independent variables. In general, the bankruptcies with an unknown status have a higher proportion in the high asset and liability category, compared to successful bankruptcies, whereas unsuccessful bankruptcies have a higher proportion in the low asset and liability categories. Approximately 12% of the organizations with successful and unsuccessful bankruptcies have assets over $1,000,000, compared to 32.26% of the organizations with an unknown bankruptcy status (ꭓ²=265.37, P<0.001). Likewise, about 2.5% of the successful and unsuccessful bankruptcies have liabilities over $10,000,000, compared to 22.94% of the organizations with an unknown bankruptcy status (ꭓ²=230.06, P<0.001). On the other hand, 57.60% of the organizations with an unsuccessful bankruptcy have assets below $100,000, compared to 40.86% of the successful bankruptcies and 44.26% of the bankruptcies with an unknown status. Three-fourths (75.20%) of the unsuccessful bankruptcies have liabilities under $1,000,000, compared to 60.81% of the successful bankruptcies and 45.84% of the bankruptcies with an unknown status.

Multivariable results

Our primary interest in this model was to examine the association between assets, liabilities, and disposition of healthcare organizations’ bankruptcy at closing (Table 2). Healthcare organizations with assets between $100,001 and $1,000,000 were 11.2% more likely to have a successful bankruptcy relative to healthcare organizations with assets less than $100,000 (P<0.001). Meanwhile, healthcare organizations with assets over $1,000,000 were 31.7% less likely to have a successful bankruptcy compared to healthcare organizations with assets between $100,001 and $1,000,000 (P<0.001). Healthcare organizations with assets between $100,001 and $1,000,000 are 11.1% less likely to have a bankruptcy with an unknown status relative to organizations with less than $100,000 in assets (P<0.001). Healthcare organizations with over $1,000,000 in assets are 12.8% more likely to have a bankruptcy with an unknown status relative to organizations with between $100,001 and $1,000,000 in assets (P<0.001) (Table 2).

Healthcare organizations with more liabilities are associated with a greater likelihood of being in the unknown category and lower likelihood of having a successful or unsuccessful bankruptcy. Compared to healthcare organizations with less than $1,000,000 in liabilities, organizations with more than $10,000,000 in liabilities are 15.0% less likely to have a successful bankruptcy (P<0.001). Similarly, relative to organizations with liabilities between $1,000,001 and $10,000,000, healthcare organizations with liabilities over $10,000,000 were 14.7% less likely to have a successful bankruptcy (P<0.001). Looking at the unsuccessful bankruptcies, organizations with $1,000,001 to $10,000,000 in liabilities were 1.5% less likely to have an unsuccessful bankruptcy compared to healthcare organizations with less than $1,000,000 in liabilities (P<0.01) and organizations with over $10,000,000 in assets were 2.8% less likely to have an unsuccessful bankruptcy (P<0.001). Compared to organizations with $1,000,001 to $10,000,000 in liabilities, organizations with over $10,000,000 are 1.4% less likely to have an unsuccessful bankruptcy (P<0.01). Finally, organizations with over $10,000,000 in liabilities, compared to organizations with under $1,000,000 in liabilities, are 1.3% less likely to have a bankruptcy of unknown status (P<0.001). Compared to organizations with $1,000,001 to $10,000,000 in liabilities, organizations with over $10,000,000 are 15.9% more likely to have a bankruptcy of unknown status (P<0.001) (Table 2). Each additional year between bankruptcy filing and closing is associated with 1.3% lower likelihood of an unsuccessful bankruptcy (P<0.001) and 1.2% higher likelihood of an unknown bankruptcy (P<0.01).

Taking a closer look at original filing chapter in relation to closing chapter (Table 3), we see that over 99.67% of the healthcare organizations filing as Chapter 7 bankruptcies closed as Chapter 7 bankruptcies, and 100.00% of the organizations filing as Chapter 9 bankruptcies closed with the same chapter. Approximately 91% of the organizations filing as Chapter 11 bankruptcies closed as Chapter 11 (90.78%), and 9.18% closed as Chapter 7. There is more variability among the organizations filing as Chapter 13 bankruptcies. While 80.00% of the Chapter 13 bankruptcies closed as Chapter 13, 13.33% closed as Chapter 7 and 6.67% closed as Chapter 11. This paper only sought to understand Chapter 7 and Chapter 11 filings as Chapters 9 and 13 are not relevant for typical healthcare bankruptcies, as they apply to municipalities and individuals rather than firms. Of the total sample of organizations filing for bankruptcy protection during the study period, only 4,976 completed the process and closed out of bankruptcy. The remaining organizations remained under the supervision of the U.S. Courts as of the data collection period.

Discussion

The healthcare sector of the U.S. economy is operating in uncertain times. Labor shortages, reimbursement challenges, and increased competition have put organizations under financial pressure. Almost 16,000 U.S. healthcare organizations have filed for bankruptcy protection since 2013. Of filing organizations, many are small to mid-sized firms with comparatively low or moderate assets and reported liabilities. This suggests that most filing organizations are smaller businesses such as physician practices rather than larger enterprises like hospitals or pharmaceutical companies. Chapter 11 policy is largely designed as a cookie-cutter framework applicable for all debtors that benefits large corporate debtors and criticized as not working well for smaller firms (35). This policy may impact the success of the smaller healthcare organizations’ ability to effectively use Chapter 11 to rescue the firm. If success rates are low, the prevalence of so many smaller business filings suggests that policymakers ought to consider the needs of smaller healthcare organizations in the Bankruptcy Code and tailor amendments to enhance the utility of Chapter 11 as a rescue tool.

Over half of the healthcare organizations filing for bankruptcy protection during the study period opted for reorganization through Chapter 11 rather than a liquidation strategy through Chapter 7. Although 55.92% of organizations originally filed to reorganize and continue operations, around 9% of these firms changed their original filing over to Chapter 7 by the close of their bankruptcy. This may be due to an inability of those firms, while in Chapter 11, to formulate a plan to successfully reorganize the firm and a determination that the firm cannot be rescued.

For the purpose of this study, bankruptcy success is defined by the organization’s ability to continue operating. Of the organizations filing for bankruptcy reorganization during the study period, around 17% can be declared a definitive success. That is the organization emerged from Chapter 11 with a plan of reorganization, received a discharge of pre-bankruptcy obligations, and continued to operate—a rescue. However, only around 3% can be considered bankruptcy failures, i.e., unsuccessful, based on their disposition. Such organizations did not emerge from Chapter 11 with a plan of reorganization, did not receive a discharge of pre-bankruptcy obligations and were mostly likely liquidated. However, many of the organizations in the study have dispositions that are unknown.

Most filings fall into an undetermined category, and these organizations may have had a successful or unsuccessful bankruptcy. For example, organizations may file for Chapter 11 and use the process and legal tools therein to reach agreements or workouts with creditors. The organization, if successful in this approach, may voluntarily exit bankruptcy without a reorganization plan, but the firm may continue to operate post-bankruptcy under these new financial arrangements. The bankruptcy would be considered a success. Other organizations may during the process be unable to reach agreements or workouts, and it may be determined that it is not a viable option to continue in Chapter 11 or to liquidate in Chapter 7. In such instances, the firm may have the bankruptcy case dismissed without any type of plan or liquidation in bankruptcy. The firm may continue to operate, may liquidate some or all assets, or cease to operate post-bankruptcy and allow creditors to exercise their collection rights. This example reflects an unsuccessful bankruptcy in terms of continued operations. However, it is not possible to determine the exact disposition without case-by-case analysis of each case filing in this category.

The time between organizational filing and bankruptcy closure appears to make a difference relative to bankruptcy disposition. Each additional year spent between filing and closing increases the likelihood of a successful bankruptcy. However, it also appears to contribute to the likelihood of an unknown outcome. One explanation for this is that given more time, organizations have an increased chance to negotiate with creditors and find a suitable solution outside of bankruptcy. The flexibility inherently built into the bankruptcy system affords this opportunity.

Research in the general business literature and on hospitals and healthcare delivery systems demonstrates a relationship between the size of the organization and the success of the bankruptcy. Simply put, larger organizations have a better chance of surviving bankruptcy reorganization than small organizations. However, this relationship did not hold in our study with medium-sized firms appearing more likely to emerge from bankruptcy successfully. One reason for this might be that larger organizations with more assets and reported liabilities are more likely to engage in complex negotiations with creditors and resolve payment issues outside of the court system. These organizations would end their bankruptcies without falling into our “successful” category. Finally, the data are ambiguous. Many of the organizations fall into the “unknown” success category, so that complicates the issue.

Limitations

Although this exploratory study provides some information about the success of bankruptcy as a reorganization strategy for healthcare organizations, the interpretation of results is limited by the data. First, the data does not indicate what type of organization is filing; only that the organization is considered a healthcare organization. Without further qualitative work to determine the kind of organization, this leaves a lot of questions related to the types of businesses filing for bankruptcy protection. Additionally, many of the bankruptcies did not have a clear disposition. The organizations without a clear disposition either left or were dismissed from bankruptcy protection, leaving their status as unknown. This might mean they came to an agreement with creditors outside of the court system, or it might mean they were dismissed from bankruptcy. Further qualitative work is necessary to fully understand what happened in these unknown cases.

Conclusions

This study is the first to explore overall healthcare bankruptcy filings in the U.S. Although data provided from the U.S. Courts showed information on every healthcare filing during our study period, a limited amount of information was available. As filings are publicly available and offer a rich description of actual organizational characteristics and financial information, future researchers might consider qualitative work to explore these filings and shed more light on the universe of healthcare bankruptcies in the U.S. Study findings indicate that small and moderate sized businesses are in need of bankruptcy relief; however, policies aimed at business reorganization are largely tailored towards large corporations. Policymakers should take heed of this and reform the codes to be more cognizant of small firms who wish to maintain operations in the healthcare sector.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the Guest Editors (Robert Weech-Maldonado and Nancy Borkowski) for the series “Healthcare Finance: Drivers and Strategies to Improve Performance” published in Journal of Hospital Management and Health Policy. The article has undergone external peer review.

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://jhmhp.amegroups.com/article/view/10.21037/jhmhp-24-78/rc

Peer Review File: Available at https://jhmhp.amegroups.com/article/view/10.21037/jhmhp-24-78/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jhmhp.amegroups.com/article/view/10.21037/jhmhp-24-78/coif). The series “Healthcare Finance: Drivers and Strategies to Improve Performance” was commissioned by the editorial office without any funding or sponsorship. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Carroll NW, Landry AY, Erwin CO, et al. Factors Related to Hospital Bankruptcy: 2007-2019. Journal of Accounting and Finance 2021;21:11-23.
2. Halleman S. Healthcare bankruptcies are rising. Here are five major filings so far in 2023. 2023. Available online: https://www.healthcaredive.com/news/healthcare-bankruptcies-rising-five-major-filings-2023/700132/#:~:text=Bankruptcies%20in%20the%20sector%20have,historic%20data%2C%20according%20to%20Gibbins
3. Johnson JR, Dempsey R. 1st Quarter 2025 Chapter 11, Healthcare, and Real Estate Distress Indices. 2023. Accessed on 13 August 2022. Available online: https://www.distressindex.com/reports/latest
4. Centers for Medicare and Medicaid Services. Historical data. 2024. Available online: https://www.cms.gov/data-research/statistics-trends-and-reports/national-health-expenditure-data/historical
5. Chee TT, Ryan AM, Wasfy JH, et al. Current State of Value-Based Purchasing Programs. Circulation 2016;133:2197-205. [Crossref] [PubMed]
6. Rau J, Huetteman E. Some Urban Hospitals Face Closure Or Cutbacks As The Pandemic Adds To Fiscal Woes. 2020. Accessed on 13 August 2022. Available online: https://www.npr.org/sections/health-shots/2020/09/15/912866179/some-urban-hospitals-face-closure-or-cutbacks-as-the-pandemic-adds-to-fiscal-woe
7. Poindexter K. The Great Resignation in Health Care and Academia: Rebuilding the Postpandemic Nursing Workforce. Nurs Educ Perspect 2022;43:207-8. [Crossref] [PubMed]
8. Grant Thornton. The growing role of private equity in healthcare. 2023. Accessed on January 8, 2024. Available online: https://www.grantthornton.com/insights/articles/health-care/2023/the-growing-role-of-private-equity-in-healthcare
9. Diaz N. How Big Tech is reinventing healthcare. 2022. Accessed on January 8, 2024. Available online: https://www.beckershospitalreview.com/disruptors/how-big-tech-is-reinventing-healthcare.html
10. Landry RJ III. Enhancing Rescue in Chapter 11: Lessons from Reform Efforts in the United Kingdom. American Business Law Journal 2020;57:227-79.
11. Beauvais B, Ramamonjiarivelo Z, Betancourt J, et al. The Predictive Factors of Hospital Bankruptcy-An Exploratory Study. Healthcare (Basel) 2023;11:165. [Crossref] [PubMed]
12. Landry AY, Landry RJ 3rd. Factors associated with hospital bankruptcies: a political and economic framework. J Healthc Manag 2009;54:252-71; discussion 271-2.
13. Adnan Aziz M, Dar HA. Predicting corporate bankruptcy: where we stand? Corporate Governance The International Journal of Business in Society 2006;6:18-33.
14. Bellovary JL, Giacomino DE, Akers MD. A review of bankruptcy prediction studies: 1930 to present. J Financ Educ 2007;33:1-42.
15. Foreman RD. A logistic analysis of bankruptcy within the US local telecommunications industry. J Econ Bus 2003;55:135-66.
16. Altman EI. Financial ratios, discriminant analysis and the prediction of corporate bankruptcy. J Finance 1968;23:589-609.
17. Holmes GM, Kaufman BG, Pink GH. Predicting Financial Distress and Closure in Rural Hospitals. J Rural Health 2017;33:239-49. [Crossref] [PubMed]
18. Langabeer J. Predicting financial distress in teaching hospitals. J Health Care Finance 2006;33:84-92.
19. Lord J, Landry A, Savage GT, et al. Predicting Nursing Home Financial Distress Using the Altman Z-Score. Inquiry 2020;57:46958020934946. [Crossref] [PubMed]
20. Puro N, Borkowski N, Hearld L, et al. Financial distress and bankruptcy prediction: A comparison of three financial distress prediction models in acute care hospitals. J Health Care Finance 2019;46:199.
21. Ramamonjiarivelo Z, Weech-Maldonado R, Hearld L, et al. Public hospitals in financial distress: Is privatization a strategic choice? Health Care Manage Rev 2015;40:337-47. [Crossref] [PubMed]
22. Bazzoli GJ, Cleverley WO. Hospital bankruptcies: an exploration of potential causes and consequences. Health Care Manage Rev 1994;19:41-51. [Crossref] [PubMed]
23. Bazzoli G, Andes S. Consequences of hospital financial distress. Hosp Health Serv Adm 1995;40:472-95.
24. McCue MJ. The use of cash flow to analyze financial distress in California hospitals. Hosp Health Serv Adm 1991;36:223-41.
25. Azam A, Ahmad N, Khan I, et al. Measurement of financial performance of selected Indian pharmaceutical companies by using the Altman’s-score model. Journal of Research Administration 2023;5:557-70.
26. Ansari B. Yawar-uz-Zaman M, Sabri R. Gauging Bankruptcy using Altman’s Z-Score: Empirical Investigation from the Pharmaceutical Sector. Siazga Research Journal 2023;2:192-201.
27. Stel'makh VS. Methodological aspects of predicting the probability of bankruptcy on the example of pharmaceutical companies. Economic and Social Changes: Facts, Trends Forecast 2019;12:115-27.
28. Hampton R. Unsettled: How the Purdue Pharma bankruptcy failed the victims of the American overdose crisis. New York: St. Martin's Press; 2021.
29. Hobbs A. Analyzing Johnson & Johnson's Bankruptcy Claim: Good Strategy or Bad Ethics? In: SAGE Business Cases Originals. London: Sage Publications Ltd.; 2022.
30. Lexa FJ, Lexa FJ. Private Equity-Backed Hospital Investments and the Impact of the Coronavirus Disease 2019 (COVID-19) Epidemic. J Am Coll Radiol 2020;17:1049-52. [Crossref] [PubMed]
31. Knox KJ, Blankmeyer EC, Trinidad JA, et al. Predicting bankruptcy in the Texas nursing facility industry. Q Rev Econ Finance 2009;49:1047-64.
32. Kitchener M, O'neill C, Harrington C. Chain reaction: an exploratory study of nursing home bankruptcy in California. J Aging Soc Policy 2005;17:19-35. [Crossref] [PubMed]
33. Doeksen GA, Clair CFS, Eilrich FC. Economic Impact of Rural Health Care. 2016. Available online: https://ruralhealthworks.org/wp-content/uploads/2018/04/Summary-Economic-Impact-Rural-Health-FINAL-100716.pdf
34. Federal Judicial Center. Bankruptcy filing data. 2024. Available online: https://www.fjc.gov/research/idb
35. American Bankruptcy Institute. Commission to Study the Reform of Chapter 11. 2014. Available online: https://commission.abi.org/full-report