HCE College Bowl 2013 Aaron Margulis Jesse Levi Andrew Meehan HOSPITAL STATUS TURNAROUND

FINANCIAL VIABILITY. STAND-ALONE HOSPITAL No Economies of Scale No Leverage with Payers & Suppliers No Physician Alignment Platform No deployed EMR LABOR SHORTAGE Alameda County is a designated RN Shortage Area (Source: OSHPD) Difficulty in recruiting physicians OPERATIONAL INEFFICIENCIES Historically High ALOS ICU ALOS continues to be extremely high CHALLENGES TO

LIQUIDITY & LONG-TERM DEBT LOAD Liquidity: 1.8 Days Cash on Hand (FY2011) High Debt Burden (negative debt service ratio; FY2011) INCREASING COSTS Wages & Salaries up by 61% ( ) MD Professional Fees up by 75% ( ) Supplies up by 24% ( ) UNFAVORABLE PAYER MIX/ REIMBURSEMENT LEVELS High Med-Cal & Uninsured Population Below Market Managed Care Reimbursement UNCERTAINTIES & POOR OUTLOOK WITH RESPECT TO ACA Expansion of Avoidable Readmission Penalties through 2014 Decreased CMS DSH Payments in 2014 Does not Address 124,000 Undocumented Aliens Residing in Alameda County

THE PLAN 3 phases

FROM RED TO BLACK PHASE 1 Restructure long-term debt Unlock liquidity from fixed assets Seek new capital partners Reevaluate and realign capital expenditures BALANCE SHEET REHAB PHASE 2 Position Hospital for acquisition, affiliation or merger that would allow for infusion of capital for: IT infrastructure Physician Alignment Vehicle PHASE 3 PARTNERSHIP Operations Redesign Strategic Cost Management Clinical Transformation Payer Contract Renegotiation

PHASE 1 FROM RED TO BLACK Net Savings: $2,243,000 Net Savings: $300,000 Strategic Cost Management WAGES & BENEFITS MD PROF FEES SUPPLY CHAIN »Wages have increased by 61% in the last five years ( ) »Benefits are at 22% (FY 2011) »Decreasing Wages by 1.25% would save $993,000 annually »Bringing Benefits down to 20% would save $1,250,000 »Constitute IM/OB Hospitalist and RAPE specialty subsidies, medical directorships and ED on-call pay »Grown by 75% over five years to nearly $6 million dollars ( ) »Cut 5% from Management Groups in exchange for longer contract periods and place more dollars in a P4P bucket. Cut 2.5% from individual providers »Supply costs have increased by 24% over last five years ( ) to over $16 million per year »Pursue a strategy of product and vendor standardization that can add more leverage to lower costs »Implement caps for high-dollar items »Develop a formal process to justify high-cost purchases especially in the presence of lower cost alternatives Net Savings: $560,000

CLINICAL TRANSFORMATION Managing Clinical Utilization Intensivist Program »ICU LOS was 17.3 days in 2012 »Our Goal: cut LOS to 4 days »Use of evidence-based guidelines per SCCM standards »Multidisciplinary team approach »12-hour in-house coverage »Net savings of $9.8 million Managing Clinical Variation Super Committee »Medical Staff Committee »Expedite approval process for evidence-based protocols and order sets »Monitoring adherence to evidence-based care for sepsis, AMI, CHF and PNA »Refer fall-outs for peer review

MEDICARE MANAGED CARE REIMBURSEMENT SRH has generated comparable reimbursement rates from Medicare Managed Care plans relative to other hospitals in the same market. Source: OSHPD Annual Financial Disclosure Report Net Inpatient Revenues per Discharge Source: OSHPD Annual Financial Disclosure Report SRH Payer Mix | Inpatient Discharges, 2011

THIRD PARTY MANAGED CARE REIMBURSEMENT SRH has generated highly unfavorable reimbursement rates from Third Party Managed Care plans relative to other hospitals in the same market. Source: OSHPD Annual Financial Disclosure Report Net Inpatient Revenues per Discharge Source: OSHPD Annual Financial Disclosure Report SRH Payer Mix | Inpatient Discharges, 2011

PAYER CONTRACT RENEGOTIATION Obtain higher reimbursement rates from third party managed care payers »Value Proposition: lower cost structure, quality care, payer will have to pay higher costs if SRH closes »Seeking 20% increase in rates, generating $2 million in additional revenue Court health plans to obtain Medicare Advantage contracts to increase volume at favorable rates, once operational efficiencies have been realized and demonstrated

NET IMPACT TO SRH: $14,903,000 PHASE ONE FINANCIAL IMPACT Strategic Intervention Financial Impact Wages and Benefits $2,243,000 MD Professional Fees $ 300,000 Supply Chain$ 560,000 Intensivist Program$9,800,000 Payer Contract Renegotiation$2,000,000

BALANCE SHEET REHABILITATION Restructure Long-term Debt Unlock Liquidity in Existing Assets Seek New Capital Partners Reevaluate and Realign Capital Investments

STRATEGIC PARTNERSHIP  Consolidation in Regional Market »Partnership between UCSF and Children’s Hospital Oakland »Potential acquisition of San Leandro Hospital by Sutter Health  Stand-alone hospitals cannot survive under health reform  Approach merger or acquisition partners  SRH offers a distinct value proposition

Source: California Public Policy Institute, 2011 IMPACT OF HEALTH REFORM  Most hospitals will benefit from the ACA »Expansion of Medi-Cal  Expectation that ACA will have negative effect on SRH »Revenues tied to clinical outcomes, quality of care and cost efficiency »Expansion of CMS penalties for preventable readmissions in 2014 »Lack of physician alignment platform hinders continuity of care »Expected decreases in DSH payments »Newly insured patients in our service area will likely obtain plans with bronze rating or silver rating »Does not address 124,000 undocumented aliens residing 1 in Alameda County

CONCLUSION Leadership Operations Balance Sheet Rehabilitation Acquisition

THANK YOU Hospital Turnaround