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J.P. Morgan
North America Credit Research
27 September 2012
•,
Kindred Healthcare
Initiating Credit Coverage with Overweight; Buy on the
8-1/4% Notes
•
Kindred Healthcare (KND) is one of the largest healthcare service
providers, with LTM revenues of $6.1 billion. Two things have
historically made it a difficult credit for many investors. First, about
half of its revenues are obtained from long term acute care (LTAC)
hospitals, the reimbursement of which Medicare has long suggested
should change. Second, a sale-leaseback many years ago means KND
has 'double leverage' via unusually high rents.
•
We think it's a good time to Overweight Kindred. Most
importantly, it seems KND will not have to contend with any
transformative changes to Medicare reimbursement for the next several
years. Medicare took skilled nursing (SNF) payments down sharply a
year ago, and it has delayed the 25% rule for LTACs an additional year
to 2013, "pending results of an on-going research initiative to re-define
the role of LTCHs in the Medicare program." Visibility of 2013 is
reasonable, helped by preliminary guidance this month. FCF looks to
be adequate, albeit sensitive to small changes in margins.
• Management wants to increase the percent of assets it owns vs.
leases. After some back and forth with Ventas, its largest landlord,
KND now plans to let the leases lapse for 54 SNFs with annual
revenues of approximately $550 million. These are generally older
assets (average age of 41 years). Between below-average margins and
capex required for upkeep the FCF impact of this shrinkage should be
minimal.
• KND 8-1/4% have underperformed since issued in May 2011.
Bonds are a little below par while the market and single-Bs have
tightened 40bps and 60bps, respectively. But now that we have
anniversaried a full year of lower SNF payments and CMS has said it
will review patient criteria, business risk seems much reduced.
•
We initiate credit coverage with an Ovenveight rating on Kindred
and a Buy on the 8-1/4% unsecured notes.
Table 1: KND Bond
Market Data as of 26-Sap-12
Coupon
Amt ISmr0
Description
Maturity
Rating
Ma
YTW
STW
Rae
5 250 .
3550.0
Sr Unsettred
1Jun•19
BNB-
$98.00
8.65%
768bp
Buy
Overweight
Moody's: 81
Outlook: Stable
S&P:
8+
Outlook: Stable
The above ratings are at the corporate level
Ticker
KND
Healthcare
David Common, CFA AC
Jared Feeney. CFA
J.P. Morgan Securities LLC
See page 10 for analyst certification and important disclosures.
J.P. Morgan does and seeks to do business with companies covered in its research reports. As a result, investors should be aware that
the firm may have a conflict of interest that could affect the objectivity of this report. Investors should consider this report as only a single
factor in making their investment decision.
www.morganmarkets.com
EFTA01108670
David Common. CFA
North America Credit Research
27 September 2012
Company Background
J.P.Morgan
Kindred Healthcare (KND) is a post acute care provider, with LTM revenues of
$6.1 billion and Adjusted EBITDAR of $846 million. KND acquired RehabCare in
June 2011 for $1.3 billion, and obtained 32 long term acute care hospitals, five
inpatient rehabilitation facilities, approximately 1,200 rehabilitation therapy sites of
service, and 102 hospital-based inpatient rehabilitation units.
The company's strategy is focused on the development of cluster market service
offerings across the U.S., providing care across the post acute care spectrum, from
the highest acute (LTACs) to the lowest acute (home health). Today, KND has 15
cluster markets and has three potential cluster markets.
Figure 1: KND Geographic Footprint and Cluster Markets
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The company has five reportable segments, including the following:
•
Hospitals — Consists of the company's long-term acute care hospitals as well as
its inpatient rehabilitation facilities. As of June 30, 2012, the company operated
118 LTAC hospitals and six IRFs in 26 states. In May, the company renewed (for
10 years) a lease (with Yentas) for 10 LTAC hospitals that was set to expire in
April 2013. These LTACs generated $276 million in revenues for FY 2011.
Revenues and EBITDAR (pre-corp) for the last 12 months were $2.9 billion and
$573 million for this division.
•
Nursing Center (SNFs) — Consists of the company's transitional care, nursing
and rehabilitation, and skilled nursing centers. As of Lune 30, 2012, the company
operated 224 SNFs, and six assisted living facilities in 27 states. In February, the
company decided not to renew leases for 54 of its SNFs, which generated
approximately $550 million in revenues for FY 2011. The current lease expires in
April 2013 (though the company has provided Yentas additional flexibility with
accelerating the transfer of those assets to new operators). Revenues and
EBITDAR (pre-corp) for the last 12 months were $2.2 billion and $294 million
for this division.
2
EFTA01108671
David Common. CFA
North America Credit Research
27 September 2012
J.P.Morgan
•
Rehabilitation (RehabCare) — Consists of the company's contract therapy
services in hospitals and long-term care settings. Revenues and EBITDAR (pre-
corp) for the last 12 months were $969 million and $142 million.
•
Home Health and Hospice (PeopleFirst) — Provides the aforementioned
services from 52 locations in eight states under the "PeopleFirst" brand. The
company has been keenly focused on expanding these capabilities. Revenues and
EBITDAR (pre-corp) for the last 12 months were $99 million and $9 million.
Figure 2: Revenue Mix
Home Health &
Hospice
1%
Skilled Nursing
Facilities
36%
Rehabilitation
16%
LTACH/IRF
capitals
47%
The hospital segment is higher-margined than the other segments, highlighting that
LTAC business conditions are still the number one driver of results.
Figure 3: EBITDAR (Pre-Corporate) Mix
Rehabilitation
14%
Home Health &
Hospice
1%
Skilled Nursing
Facilities
29%
LTACFUIRF
capitals
56%
Over 60% of the company's revenues are exposed to government reimbursement,
which has been under increased scrutiny (see Recent Credit Profile below). Note that
the "Business-to-Business" payor below is from the company's rehabilitation
division (contract therapy services).
3
EFTA01108672
David Common. CFA
North America Credit Research
27 September 2012
Figure 4: Payor Mix
Medicare
40%
Medicaid
16%
J.P.Morgan
usiness1o.
Business
15%
Commeraal
Insurance/ Private
29%
History - Separation from Ventas
• 1985: Company was founded as Vencare Inc, an operator of LTACHs.
•
1989: Company went public and changed its name to Vencor, Inc (based on its
early focus on ventilator-dependent patients).
•
1995: Vencor made a $1.6 billion acquisition to acquire Hillhaven Corporation,
an operator of more than 300 SNFs.
•
1997: Balanced Budget Act changes SNF reimbursement from cost-plus to a
prospective payment schedule (PPS) leading to uncertainty in future margins.
•
1998: Vencor split into two companies, in an attempt to unlock shareholder value
by "REIT-ing" the company. Ventas, which took with it the real estate assets,
became a REIT and Vencor become the operating company.
•
1999: The decline in SNF payment rates exceeded management's expectations,
and cost-save opportunities turned out to be lower. Vencor filed for Chapter 1
bankruptcy protection, but got about a 20% rent reduction from VTR to reflect
the non-arm's length nature of the original lease arrangement.
As part of the bankruptcy reorganization, Vencor changed its name to Kindred
Healthcare.
Recent Credit Profile
CMS Rate Reduction for SNFs
In July 2011, CMS announced the final SNF rates for FY 2012, an average 11.1%
reduction for all SNFs. This rate correction was made to address the spike in
reimbursement associated with the introduction of the RUGS-IV (Resource
Utilization Groups Version 4) payment schedule. Under the new payment system, the
government saw a significant increase in reimbursement, due to a shift in utilization
among the therapy modes under the new RUGS-IV that differed significantly from
CMS projections. As a result, CMS decided to implement a correction for fiscal
2012.
Following the cut, KND appeared to have underestimated the impact over the course
of several quarters, increasing the annual revenue impact estimate (to both its SNF
and contract therapy businesses) from the midpoint of $102 million in August 2011
to $150 million in February 2012.
4
EFTA01108673
David Common. CFA
North America Credit Research
27 September 2012
J.P.Morgan
Despite underestimating the revenue headwind, it has been largely offset by cost
savings. While management had first anticipated $55 million in synergies for 2012
associated with the RehabCare acquisition, the company has since realized
$70 million through 2Q12. Further, the company expects to realize $50-$55 million
in cost savings from SG&A reductions over the course of 2012. Management expects
4Q12 to be the first quarter where the full impact of the RehabCare synergies and the
SG&A reductions will be evident.
RehabCare Acquisition
KND acquired RehabCare in June 2011 for $1.3 billion (about 8x pre-synergies
EBITDA), and obtained 32 long term acute care hospitals, five inpatient
rehabilitation facilities, approximately 1,200 rehabilitation therapy sites of service,
and 102 hospital-based inpatient rehabilitation unites. As noted above, while
management had first anticipated $55 million in synergies for 2012 associated with
the RehabCare acquisition, the company has since realized $70 million through
2Q12.
Future Credit Profile
Acquisition Growth
The company plans to "aggressively" expand home health and hospice services in its
cluster markets, services that management sees as "higher-margin growth business."
Today, the business is at about a $200 million run rate (post recent acquisitions
including IntegraCare discussed below). As KND recently indicated, organic growth
rates in home health and hospice are in the 6%-8% range, compared to 2%-3% in
LTACHs, and about flat in SNFs. The higher growth rates, in conjunction with the
company focused on delivering care across the post acute care continuum, will likely
lead to significant expansion in home health and hospice, resulting in a change to the
revenue mix in the future. KND expects to be able to grow the home health and
hospice business organically (including de novos) by approximately 10% a year, with
an additional $75-$100 million of growth per year via acquisitions.
Earlier this month, KND acquired IntegraCare, a home health and hospice provider
predominantly located in northern Texas, for $71 million (I .0x revenues) plus a
possible $4 million cash earn-out. The company generates $71 million in revenues
and EBITDA of approximately $9 million. Management expects additional organic
growth opportunities through expansion into KND's existing Houston market. Paul
Diaz indicated at a recent investor conference that he would like to make five more
deals like IntegraCare over the next 18 months.
LTACHs Get Relief
In August, CMS announced the final rates for LTACHs, resulting in a +1.7% update
for fiscal 2013. KND management indicated that the net effect (before sequestration)
for the company will be a "slight" decline in reimbursement for its facilities.
In any case, these rates and the one-year extension of the 25% rule appeared to
positively surprise many investors, with KND's equity rising 19% on the day after
the proposal in April. Earlier this year, MedPAC recommended no update in rates,
with many investors fearing the possibility of CMS incorporating the full impact of
budget neutrality (3.9% cut that was set to go into effect in calendar year 2013), and
5
EFTA01108674
David Common. CFA
North America Credit Research
27 September 2012
J.P.Morgan
the expiration of the very short stay outlier and 25% rule moratoria. Ultimately, the
following is the final update for fiscal 2013:
•
1.3% budget neutrality phase-in (3.75% over three years).
•
A payment reduction for very short stay outliers of 0.5%.
•
One-year extension of the 25% rule, 'pending results of an on-going research
initiative to re-define the role of LTCHs in the Medicare program."
The announcement of a 1.7% net increase for LTACHs is a win for the industry, as
the outcome was arguably at least a 6% swing, from the context of what the rate
could have been with the full impact of budget neutrality in place. Furthermore, the
delay in the 25% rule is a positive for those with significant exposure to hospital-in-
hospital (HIE) facilities, the full impact of which (while challenging to estimate
given the number of assumptions) could be in the $50 million context for some of the
H1H operators, but the impact to KND would likely be materially lower.
It's also possible that the 25% rule could be eliminated in entirety. CMS states that it
has delayed the rule "pending results of an on-going research initiative to re-define
the role of LTCHs in the Medicare program." We believe that this research initiative
is likely referring to patient criteria. Our sense was that industry-sponsored 'criteria'
had been sufficiently diluted that they came nowhere near CBO's score of the cost to
replace. But even if we don't know the details, the fact that CMS is considering this
is a win in itself for the industry. As discussed at an investor presentation earlier this
month, KND believes the criteria bill will score $500 million to $1 billion in savings.
With the upcoming election taking center stage, we figured 'criteria' would only
have an opportunity for inclusion in Congress's "lame duck" session.
Real Estate — More Ownership, Less Leasing
In recent years, KND has developed a greater interest in developing its asset base,
reacquiring leased assets when compelling value propositions present themselves. As
noted by management this month, the company has purchased previously leased real
estate for approximately $76 million, which includes three LTACHs. Recently,
management has addressed its view on acquiring real estate, which per the figure
below, is the most expensive decision with respect to capital allocation. Given this
and the other materially more accretive opportunities, we would expect the company
to focus less on repurchasing its rented assets and continue to build out its franchises
(especially home health and hospice; see low multiple and high EPS accretion;
further discussed above).
6
EFTA01108675
David Common. CFA
North America Credit Research
27 September 2012
Figure 5: KND's Capital Investment Opportunity Set
I
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SNF Divestitures
As mentioned above, in February, the company decided not to renew rental contracts
for 54 of its SNFs, which generated approximately $550 million in revenues for FY
2011. The current contract for these facilities expires in April 2013 (though the
company has provided Yentas additional flexibility with accelerating the transfer of
those assets to new operators).
2013 Guidance
Earlier this month, KND reaffirmed 2012 guidance and introduced preliminary
guidance for 2013. Please see the guidance below:
Table 2: KM) Guidance
$mm (ex - EPS)
2012
2013
Updated
Previous
New
Revenues
62 billion
No change
5.9 Mien
EBITDAR
868 to 884
No change
806 to 825
Rent
432
No change
389
DBA
201
No change
190
Interest Exp.
107
No change
110
EPS
1.35 to 1.55 per share
No change
1.20 to 1.40 per share
CF from Opt
260 to 280
240 to 260
230 to 250
Routine Capex
135 to 145
125 to 135
120 to 130
Discretionary FCF
85 to 90
No change
90
The guidance for 2013 assumes a reduction in revenues due to Medicare
reimbursement rate reductions of $90-$100 million (due to LTACH budget neutrality
phase-in and sequestration). We would expect sequestration and budget neutrality to
result in revenue reductions of approximately $65 million and $30 million,
respectively. Further, it assumes that the results of the 54 SNFs (whose rental
agreements expire in April 2013 and are not being renewed) are classified as
discontinued operations as of January I, 2013.
7
EFTA01108676
David Common. CFA
North America Credit Research
27 September 2012
Kindred Healthcare, Inc.
KND
FINANCIAL SUMMARY ($ ten)
Fiscal yesnend December
Mon statement BY to
Total revenues
/tStmth
S3bneS, AlgtS
benefils
Suptits
Real
Obit M6141/15 openses
WpyrrerldWgeS
Total Operating expense
% Olsen (events
Actual
Ful Year
EYE 20)9
I
$4270
$2483
$333
$348
$886
$0
9(9%
Adstsiod OMAR
E1317/146 Mavis
Y/Y [toot
$578
115%
Aqrated EBITDA
ESIMA AtzuMt
WY Groot
1229
54%
AdjAntents
EMMA
EBITDA Manta
Depreoalta sed antelainen
EBIT
Can Ibis) al doesbl.re
operstom
Loa antulate renCentrel El; tere-StS
lemma (ass) attributable to Kindred
Ovate ilass) kat CiSCCrlited o;erakes. net of name
Net Mem*
Bate Mures Atsts-fin2
ENT Lamp
Net Intent Expense
Otte
EEO
lyre Imes
Mean ear rate
bloat* from eating operations
Banc EFS -naninurg
Elleced shales outstanelng
DAted EPS catering cps_
Cub love snatnis
Net Income (toss)
Delman:a and anteltakei
Fronton la denbliel acccuols
Otte
Meting espial
Cash low from optalira activities
Maintenance Own
E(scregonary ICE
Dscretinlare Casex
Free Caste Flow
Anse Snow. aro Ovntettextei
8
$10
$126
$94
2%
Ise)
$16
$102
$39
35%
$63
$1
0 23)
140
50
140
38 3
$105
385
5t,04
40
126
19
43
Is)
234
(102)
132
44)
88
Actual
FW Yeae
FYE 2010
Actual
1011
3141m-11
Actual
2011
30-An.11
Actual
3011
3040.11
Actual
4011
31-Deol 1
Actual
Ft1 Yet
FYE 2011
Actual
1012
3144a,.12
Aebal
2012
30-Ati.12
Estimate
3012
30-Se -12
Estimate
4012
31-Deol2
KILO
11.192
51283
$1314
11323
$5.512
11480
11.538
51423
51.562
21%
9.4%
1/5%
418%
3(2%
267%
325%
188%
26%
26%
52.K6
$679
$765
$901
$911
$3.255
$945
$907
$896
$501
$342
$80
$97
$108
$108
S 02
$111
$108
$107
$109
$357
$81
$96
$106
$107
I
$
C
Q
$399
$108
$108
$107
$109
$919
$259
$287
$305
$313
11.164
$311
$313
$316
$323
SO
$0
$0
$27
$103
$129
$1
$0
SO
50
14.154
11.120
11245
1140
11411
55.351
114711
11.436
11428
11.444
953%
919%
95.3%
954%
101.2%
969%
914%
915%
916%
924%
$574
$171
$182
$211
1101
1761
$215
$219
DM
$231
732%
114%
14.1%
119%
132%
138%
116%
1(3%
13.6%
14.8%
-0.6%
17.8%
211%
70.9%
27.4%
332%
2Se%
206%
.1.6%
152%
$217
MO
118
$105
$94
1365
$107
$112
$161
$122
50%
67%
61%
69%
62%
66%
6.8%
7.3%
66%
7.8%
-16%
318%
MI%
2086%
40.9%
667%
319%
29.7%
-(4%
29.5%
$11
$7
$38
$37
$112
$151
$3
$12
$3
$3
12C6
$73
$68
018)
$171
$104
$100
$98
$119
4.7%
6.7%
3.7%
4.5%
41%
31%
46%
45%
64%
7.6%
$122
$33
$38
$47
$48
$49
$50
$49
551
144
$10
$10
$22
($87)
$5
$55
$50
148
$68
2%
3%
1%
I%
.4%
0%
3%
3%
3%
4%
(57)
$6)
($23)
026)
036)
081)
0 27)
027)
(128)
(s28
$13
53
$3
$3
$3
$12
$3
$3
$0
$0
$90
138
(110)
RN
0 901
(63)
$31
$28
$20
140
S34
$16
03)
02)
017)
0 7)
$13
$11
$7
$14
MO%
0%
34%
163%
19%
11%
47%
41%
35%
35%
$55
$22
(17)
$1
0 73)
056)
$19
$15
$13
$26
$1
($o)
$1
$1
$1
$3
$0
0 0)
$0
50
(SO)
50
$0
$0
$0
50
$0
$0
$0
50
156
122
($1)
12
0 72)
054)
$19
$15
$13
$28
SO
50
$0
0 0)
30
50
(SD)
$0
$0
$0
$56
$22
($8)
12
0 73)
($53)
$18
$16
$13
128
357
39.0
1-12
51.3
51.3
613
51.6
51.7
51.7
51.7
51 46
$057
0013)
9103
01401
(stio)
9115
$0.30
$025
$051
336
39.5
432
51.4
51.3
*62
51.6
51.7
51.7
51.7
51 46
$056
(91131
9103
01401
($1.16)
9115
50.30
$025
$551
58
22
PI)
2
172)
(SI)
19
15
13
26
172
33
38
47
48
168
49
50
49
51
24
6
8
8
13
7
8
7
7
33
2
(13)
27
115
2
(6)
6
6
(25)
1161
7
117)
159)
(0)
113)
19
34
210
6
57
36
154
131
63
96
124
009)
101
125)
22
0 4)
RN
137)
30
C38)
121
(133)
21
((
12)
(26)
(29)
24
(45)
50
N5)
80
(513).
110
(14)
144)
118)
(11)
112)
191
Nt
33
11
(43)
011
120) al
t67
r62
1
11
12
71
J.P.Morgan
Estimate
FLI1 Yea,
FYE 2012
16202
123%
$1650
$436
$432
$1263
II
55382
922%
5873
14.7%
14.7%
$111
7.1%
20.8%
$22
$419
48%
$199
$221
4%
($109)
$6
$118
$45
35%
$73
$0
$0
$73
iiso)
$73
51.7
$1.41
51.7
41.41
p
73
193
18
9
(30)
260
(140)
118
(401
le
Estimate
FulYeae
FYE Z113
Actual
LTM
5/Jun12
$5,891
16.153
50%
3/.6%
$1434
5.16131
$412
$435
3389
$428
$4257
$1.242
$0
$130
$1492
UV)
93.2%
95.9%
$800
$846
73.6%
117%
.63%
42.0%
$411
1418
7.0%
6.8%
.68%
741%
$12
$185
$399
$253
6.8%
d.1%
$191
$194
$208
$80
d%
1%
(51111
1$1051
50
$12
198
(134)
$34
$4
35%
•13%
$63
0 311
$0
$2
$0
$0
163
0361
$0
($0)
$63
11361
52.7
51.7
$1.19
00.71)
52.7
51.7
$1.19
00.71)
63
1361
191
151
28
31
las
1451
prat
236
152
(125)
(125)
111
27
1251
1851.
88
(581
EFTA01108677
North America Credit Research
27 September 2012
Kindred Healthcare, Inc.
FINANCIAL SUMMARY IS mn)
Ads
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Actual
Mewl
Mewl
Actuai
rj Yea
FyI Veer
1011
2011
3011
4011
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$141
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1141
$361
$36,
$36,
$351
$351
$351
5590
$1,410
$1,410
$149
$1,499
$1,499
$899
$1541
$1541
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5967
$1.011
11.058
$1.379
$1390
$1221
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$1114
$1,357
$1,406
$2.019
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$2961
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$131
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51.488
51,484
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186
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3.31
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2.76
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$578
$574
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$634
$721
$764
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546
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9
EFTA01108678
David Common. CFA
North America Credit Research
27 September 2012
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10
EFTA01108679
David Common. CFA
North America Credit Research
27 September 2012
J.P.Morgan
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11
EFTA01108680
David Common. CFA
North America Credit Research
27 September 2012
J.P.Morgan
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