In spite of low rates, hospitals continue to borrow in variable rate mode as new debt structures have eliminated much of the risks and offer a lower cost of funds. But to capture savings in an uncertain rate environment still requires a long-term approach.

In A Nutshell…

  • Over time, variable rate debt tends to be cheaper than fixed rate debt due to the slope of the yield curve and lower credit spreads.
  • New variable rate structures like bank direct placements involve less risk than LOC-backed bonds.
  • Large health systems with strong ratings and liquidity are heavier users of variable rate debt.
  • The right mix of variable/fixed depends on the type of debt and should be discussed with rating agencies.

History Shows Variable Rate Beats Fixed Rate

Historical rates for the last 20 years show some interesting trends:

  • Short term rates are consistently lower than long term rates. Except for a handful of very brief spikes, the SIFMA weekly reset index traded well below the MMD 20-year “Aaa” index. Currently, SIFMA is about 250 basis points lower than the MMD;
  • Over 20 tyears, SIFMA averaged 2.5%, about 50 basis points below the current MMD (April 2012);
  • For periods of less than 20 years, SIFMA at times traded significantly above the 20-year average (1995-2001, and again in 2006-2009).

Predicting the future can be hazardous, but based on historical rates, a hospital borrowing variable rate today can:

  • Save 250 basis points –if rates stay at current levels;
  • Expect to save 50 basis points vs. MMD if SIFMA returns to the historical average over the long run;
  • Expect less savings –or even dissavings– over shorter time periods.

Variable Rate Debt Carries Lower Credit Spreads

50 basis points a year doesn’t leave much safety cushion, but there is more to variable rate debt than indexes.

Whether borrowing SIFMA, percentage of Libor, or MMD, all hospitals pay a credit spread to compensate investors for taking on the borrower’s credit risk. Variable rate structures currently offer lower spreads than public offerings (the preferred structure for fixed rate borrowing). In the public bond markets, spreads are consistent across maturities, as MMD already compensates investors for tenor: the 30-year MMD is normally higher than the 10-year MMD. With variable rate debt however, SIFMA does not compensate lenders for term risk, so the longer the term, the higher the spread the bank needs to charge. All else held equal, bank facilities have a shorter term than fixed rate bonds so they carry a lower spread. It also helps that banks have more detailed information, better analytics, and right now, are aggressively courting hospital deposits and other business.

A “BBB+” hospital borrowing variable for 7-10 years can negotiate savings as much as 50 basis points over a fixed rate public offering. So now we’re looking at total expected savings of 100 basis points.

New Bank Structures Are Less Risky

Traditional variable rate debt presents risk, but bank direct placements have effectively reduced or eliminated its two most significant components:

  • With an LOC, bonds put back to the hospital must be either remarketed or paid in full before the LOC expires. Bank direct placements are not remarketed, so the bank cannot put them back;
  • Bank placements go out longer than LOC’s (up to 10 years or more), which allows for more amortization so reduces renewal/refinancing risk.

Tax and credit risk remain in bank placements. Tax risk is the possibility that changes in the tax code makes tax-exempt indexes more expensive. Credit risk is the risk that the hospital has to pay a higher credit spread if downgraded. Fixed rate bonds transfer these risks to bondholders, but not so with LOC-backed bonds or direct placements.

Finding The Proper Mix

Variable rate debt creates risk not found in fixed rate debt, so too much of it can negatively impact a hospital’s financial position and bond ratings. When deciding on the right mix of fixed and variable rate debt, it sometimes comes down to Board preferences, but rating agencies can also provide a few insights:

  • Moody expects the median hospital to keep twice as much cash and unrestricted investments on hand as put debt, so it can be paid off in a hurry;
  • Moody also reported last year that the median mix of put debt to total debt was 18%, but this ratio varies greatly depending on credit quality: “Aa” providers are heavy users with 41% in put debt, while “Baa” providers are more conservative with only 8%. There is a strong correlation between cash on hand and ratings, so it makes sense that higher-rated borrowers have more cash and capacity for put debt.

Rating agencies are not as helpful with bank direct placements and other forms of non-puttable debt. Moody said it considers more than 70% debt in variable rate mode (before swaps) as an “analytical red flag”, but that was when LOC-backed debt was the only way to go. Still, 70% is more than most hospitals would tolerate today for any type of variable rate debt, put or non-put.

To get more accurate feedback from rating agencies, the best option may be to have an informal discussion with an analyst, or pay for a private rating. In either case, it’s best to have a specific scenario — rating agencies get nervous about anything that could be interpreted as dispensing financial advice.


Is the opportunity to save an average of 1% enough for hospitals to take on the risks found in variable rate debt? Many standalone hospitals don’t think so, but most larger, highly-rated health systems do. In spite of today’s very low fixed rates, over the long run, the proper type and amount of variable rate debt can still be expected to provide a cost advantage and keep risk at a manageable level.