Kkr to file chapter 11 for Envison (for real this time)

[aneftp]

Biggest difference between America and the old world is a lack of an aristocracy. In England you can have a lot of money, but you haven’t ‘made it’ with the in crowd unless you were born into a prominent family or get some kind of peerage. So money is nice but it’s not the biggest social currency, whereas in the US the amount of money you have is the sole determinant of your social standing. Was a good thing for awhile, but the wealth concentration and intergenerational wealth transfer is starting to resemble an aristocracy with none of the manners.

Most of the people in my neighborhood are worth millions (Homes go
Between 1-5 million). Many people have beach places as well.

I feel poor in my hood. My sibling is worth over 15 million and they claim they are middle class.

The field goal posts are always moving in life.

Ironically the guy down the street is in his 40s and worth a couple of billion but sends his kids to public school.l

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[GravelRider]

Quest for status/access to resources have always been hardwired into us since they increase the odds of our DNA existing/propagating. Money serves as the primary tool to achieve this is modern society. The concept seems to be more hardwired in the US, compared to other countries. Technology has made this worse (eg. social comparison, consumerism etc)

That’s definitely a part of it, but you really only need a couple of million to ensure continued propagation of your genes. It’s really the fear of death that drives humanity. Religion is truly the opiate of the masses and most extremely wealthy know that this life is it. Once you’re dead, your organic matter decays back into the Earth and everything you’ve done up until then is pretty darn meaningless on a macro level. Extreme generational wealth is the closest thing humans have to eternal “life.” You can either be Genghis Khan or you can ensure a wealthy family lineage that exists centuries into the future.

 

[DesiredMemberName?]

Vanity of vanities, saith the Preacher, vanity of vanities; all is vanity.

 

[abolt18]

This should be made illegal. Disgusting what people do for money.

I especially think it should be made illegal for private equity to be involved in healthcare in any way. When the only thing that matters is profits, patients suffer and quality of care decreases.

 

[BLADEMDA]

That’s definitely a part of it, but you really only need a couple of million to ensure continued propagation of your genes. It’s really the fear of death that drives humanity. Religion is truly the opiate of the masses and most extremely wealthy know that this life is it. Once you’re dead, your organic matter decays back into the Earth and everything you’ve done up until then is pretty darn meaningless on a macro level. Extreme generational wealth is the closest thing humans have to eternal “life.” You can either be Genghis Khan or you can ensure a wealthy family lineage that exists centuries into the future.

I disagree that "religion" is just a farce or an "opiate." The idea that there is a higher power and a "soul" for humans is almost universal across the planet.
The notion that we have a creator and we will answer to him/her is not just a belief in heaven but rather hell as well. My savior is not just a God of redemption but one of judgment as well. One day you will answer to GOD and be judged. No amount of money or generational wealth changes that fact.

Death is an inevitability for all of us. It is the final phase of life. The fact you believe death marks the end of your soul is not shared by billions of people on this planet.

Mark. 8 Verses 34 to 38
[36] For what shall it profit a man, if he shall gain the whole world, and lose his own soul?

 

[UscGhost]

I disagree that "religion" is just a farce or an "opiate." The idea that there is a higher power and a "soul" for humans is almost universal across the planet.
The notion that we have a creator and we will answer to him/her is not just a belief in heaven but rather hell as well. My savior is not just a God of redemption but one of judgment as well. One day you will answer to GOD and be judged. No amount of money or generational wealth changes that fact.

Death is an inevitability for all of us. It is the final phase of life. The fact you believe death marks the end of your soul is not shared by billions of people on this planet.

Mark. 8 Verses 34 to 38
[36] For what shall it profit a man, if he shall gain the whole world, and lose his own soul?

The belief in a higher power has just been the way humans rationalize things they don't understand. Whether its praying for rain during a drought, or praying for someone to recover from an illness they don't understand, it's human nature to look for the "why".

When humans don't understand the "why" they insert a higher power. Once they figure out the "why" then they no longer do the rain dance and sacrifice a goat to the gods in order to get a bountiful crop, and instead establish irrigation and use fertilizer.

That's why there are so many different gods and religions. It's all made up.

 

[linkin06]

I disagree that "religion" is just a farce or an "opiate." The idea that there is a higher power and a "soul" for humans is almost universal across the planet.
The notion that we have a creator and we will answer to him/her is not just a belief in heaven but rather hell as well. My savior is not just a God of redemption but one of judgment as well. One day you will answer to GOD and be judged. No amount of money or generational wealth changes that fact.

Death is an inevitability for all of us. It is the final phase of life. The fact you believe death marks the end of your soul is not shared by billions of people on this planet.

Mark. 8 Verses 34 to 38
[36] For what shall it profit a man, if he shall gain the whole world, and lose his own soul?

It’s great that you find much benefit and enrichment with your faith, but why must you condemn others who weren’t raised in a judeo-Christian society to judgement and condemnation presumably for not being of the same faith? Imagine you were raised in India where the vast majority of the daily life likely revolves around Hinduism or Islam. These faiths and one billion people are to be condemned? I think religion is great if it’s not used to force others to your beliefs, which historically is how it often has passed.

 

[doctalaughs]

We throw so much talent at this it’s disgusting. People fight over getting into Ivy League just so they can have the credentials to maybe get a job at one of these parasitic firms. This is what we waste our time on.

Disgraceful

I have a friend who is private equity at KKR specializing in healthcare deals. He’s “middle management” - nowhere near the top but still makes 1+ mill/yr in bonuses.

The amazing thing is that he believes (or at least says) that they are doing good in the healthcare space. Some mumbo jumbo about how capitalism needs them to function, liquidity, economies of scale blah blah blah

Definitely deluded or they just indoctrinated him over the years (or ok with lying outside). He definitely doesn’t see the destruction PE has done to our healthcare system in the USA.

 

[anaesthetic]

I disagree that "religion" is just a farce or an "opiate." The idea that there is a higher power and a "soul" for humans is almost universal across the planet.
The notion that we have a creator and we will answer to him/her is not just a belief in heaven but rather hell as well. My savior is not just a God of redemption but one of judgment as well. One day you will answer to GOD and be judged. No amount of money or generational wealth changes that fact.

Death is an inevitability for all of us. It is the final phase of life. The fact you believe death marks the end of your soul is not shared by billions of people on this planet.

Mark. 8 Verses 34 to 38
[36] For what shall it profit a man, if he shall gain the whole world, and lose his own soul?

Majority belief is not proof of existence. Don’t get it twisted. People thought a lot of things (e.g., handwashing is useless, germ theory is wrong, gay people are bad, black people are property, vaccines cause COVID, etc.). Doesn’t make it any more true than Donald Trump being God’s imperfect vessel.

Personally, I have trouble believing in the words of a brown haired, blue eyed Caucasian schizophrenic in the Middle East warning me about impending doom if I don’t follow the words of his invisible dad in the sky who will punish me if I don’t do what daddy says.

If Jesus existed today, he would be at a highway intersection on your drive home from work. Probably needs to pull himself up by his sandal straps and stop begging for handouts.

 

[coffeebythelake]

I have a friend who is private equity at KKR specializing in healthcare deals. He’s “middle management” - nowhere near the top but still makes 1+ mill/yr in bonuses.

The amazing thing is that he believes (or at least says) that they are doing good in the healthcare space. Some mumbo jumbo about how capitalism needs them to function, liquidity, economies of scale blah blah blah

Definitely deluded or they just indoctrinated him over the years (or ok with lying outside). He definitely doesn’t see the destruction PE has done to our healthcare system in the USA.

That 1+ million a year is paid for by taxpayers when they declare bankruptcy. Broken capitalism loopholes that these parasites suckle from.

 

[anbuitachi]

rich and powerful make the rules. PE not gonna go away anytime soon. also vast of public have no idea what PE is. the country is very poorly educated.

 

[aneftp]

That 1+ million a year is paid for by taxpayers when they declare bankruptcy. Broken capitalism loopholes that these parasites suckle from.

I don’t have a problem with people making money. I love capitalism.

I do have a problem with leverage deals where there isn’t any consequences if those deals
Go bad.

As long as govt allows these “legal “ leverage deals that have gone bad with little consequences to the buyer (and sellers). It will always continue

Imagine student loan like near impossible to discharge laws for kkr. Imagine if they truly on the hook for 7 billion in debt. Kkr would have to prove they are insolvent. And kkr is not insolvent.

They would think twice about making these deals. Simply wouldn’t be worth the risks. If the company or even the most senior partners were responsible for the debt.

We are all pawns in the game. Guys like That GameStop dude plotkin is laughing to
The bank as
He keeps his money and buys the nba charlotte hornets.

 

[nimbus]

rich and powerful make the rules. PE not gonna go away anytime soon. also vast of public have no idea what PE is. the country is very poorly educated.

For example…..

Susan Collins Backed Down From a Fight With Private Equity. Now They’re Underwriting Her Reelection.

The Maine Republican senator has become the No. 1 Senate recipient of private equity donations.

www.propublica.org

 

[BLADEMDA]

It’s great that you find much benefit and enrichment with your faith, but why must you condemn others who weren’t raised in a judeo-Christian society to judgement and condemnation presumably for not being of the same faith? Imagine you were raised in India where the vast majority of the daily life likely revolves around Hinduism or Islam. These faiths and one billion people are to be condemned? I think religion is great if it’s not used to force others to your beliefs, which historically is how it often has passed.

I condemn nobody. I am just a man. I have neither the power nor wisdom for judgment of another human being's final destination. If in some way you mistook my post for condemnation or a message for damnation you are mistaken. I am a very tolerant person when it comes to religion and personal faith.
I was simply stating my interpretation of scripture as to my belief in the one true God. The God of Abraham, Isaac and Jacob as I understand HIM. Again, I make no judgment on the other religions of the planet in terms of whether my one true God is the only version of acceptability. My personal beliefs do not mean I need to condemn others.

I would never "force others" to my beliefs or even want to do so. Only those who willingly accept the one true GOD with their hearts and minds are truly saved and forgiven. Only through the TRUTH and the WORD can FAITH be given to others. It's a gift from GOD never to be bestowed with malice or hatred towards others.

Ephesians 2:8–9 affirms this: “By grace you have been saved through faith; and that not of yourselves, it is the gift of God; not as a result of works, so that no one may boast.”

ROMANS 13:10- Love does no wrong to a neighbor; therefore love is the fulfilling of the law.

 

[vm26]

Most of the people in my neighborhood are worth millions (Homes go
Between 1-5 million). Many people have beach places as well.

I feel poor in my hood. My sibling is worth over 15 million and they claim they are middle class.

The field goal posts are always moving in life.

Ironically the guy down the street is in his 40s and worth a couple of billion but sends his kids to public school.l

Agree about the goal posts moving however think this is more of a perceptional issue propagated by consumerism/social comparison etc...Most specialty physician income puts them in top percentile, however one can always see others who have more...Also big difference between being a high earner versus generational wealth.

 

[nimbus]

AmSurg to buy Envision's ASCs

Following plans to file for Chapter 11 bankruptcy, Envision Healthcare reached a restructuring agreement with its stakeholders.

www.beckersasc.com

 

[secretasianman]

AmSurg to buy Envision's ASCs

Following plans to file for Chapter 11 bankruptcy, Envision Healthcare reached a restructuring agreement with its stakeholders.

www.beckersasc.com

I don’t really understand this but I imagine this magically makes all the bad debt go away.

 

[aneftp]

I don’t really understand this but I imagine this magically makes all the bad debt go away.

It’s like GM going BK. The bad GM got left behind with all the debt.

The good GM emerge from bankruptcy with no debt.


The real issue is who really controls the “good” parts of envision. The amsurg division is the physical surgery centers and always has value. I’m shocked the creditors who are getting shafted are letting the good part of Envison emerge from
This.

Seems like a lot of side shady deals.

Of note. HCA when it was in crisis. Many of the executives went to work for amsurg next door in Nashville. Governor and us senator Rick Scott and hca have very strong ties. So many of the amsurg executives have strong tires to hca and Rick Scott. Of course amsurg purchased Sheridan in 2013 for 2.9 billion. And many of the hca anesthesia contracts were tied to Sheridan and amsurg.

It’s all interconnected Mafia game here folks.

 

[Fpg1245]

Isn’t this a fairly common way to restructure your bankrupt company?

Put the assets and profitable portions in the good company and the poor performers into the bad company. Now you have two separate legal entities right?

 

[secretasianman]

Isn’t this a fairly common way to restructure your bankrupt company?

Put the assets and profitable portions in the good company and the poor performers into the bad company. Now you have two separate legal entities right?

Only the creditors are somehow okay with this.

 

[BLADEMDA]

Under terms of the restructuring, Envision and its ambulatory unit will be owned separately by lenders. Its ambulatory unit will purchase Envision’s surgery centers for $300 million, plus a waiver of intercompany loans held by the unit. All of Envision’s debt, with the exception of a revolving credit facility for working capital, will be equitized or canceled, deleveraging about $5.6 billion, according to the company.
Envision’s clinical operations will continue in the meantime without interruption, the company added.

________________

The lenders took over the profitable portions of the business. KKR is now out of Envision completely. The lenders now own Envision, Amsurg and the surgery centers. I assume the lenders will demand profitability by increasing hospital stipends or canceling contracts entirely. The lenders will try to restore Envision to profitability then sell it so the cycle can repeat itself. This time around new bond buyers won't be suckered into a bad deal and if they issue bonds, it will be junk bonds at 12-14% interest. The new management must restore profitability at all costs.

 

[UscGhost]

You will probably just see the loss of the "growth at all costs" strategy.

Will depends on which state they are in. Some states and locations, increasing market share can increase profit margins, so it can make sense to pick up a less lucrative contract.

But no more picking up bad contracts for the sake of growth.

Probably trim some of the admin fat, etc

 

[midazzoler]

Did anybody notice in a WSJ article it said the KKR fund that held Envision still made 19% annualized while holding Envision? Feel bad for the providers but damn I wanna know how you can run a company into the ground and still come out on top. I promise I would only use that power for good and not evil.

.

 

[Gasworks]

Us non envision folks are sitting here salivating over the formerly “protected” Amsurg centers and their soon to be replaced envision docs. Good times!

 

[CubsDynasty]

G

You will probably just see the loss of the "growth at all costs" strategy.

Will depends on which state they are in. Some states and locations, increasing market share can increase profit margins, so it can make sense to pick up a less lucrative contract.

But no more picking up bad contracts for the sake of growth.

Probably trim some of the admin fat, etc

i mean they’ll be trimming everything not just admin no? With NSA and labor costs unchanging, if a practice isn’t already incredibly profitable or they can’t make everyone staff 4:1 they’ll just cut it because the game is over.

 

[nimbus]

ASA/CSA would never do this. Nice to see AAEM take up the cause.

ER Doctors Vow to Pursue Case Against Envision Despite Bankruptcy - KFF Health News

The lawyer for an emergency physicians group says its lawsuit against Envision Healthcare should be allowed to proceed even though the company has filed for Chapter 11 protection.

kffhealthnews.org

 

[Robotic Wis-Hipple]

You will probably just see the loss of the "growth at all costs" strategy.

Will depends on which state they are in. Some states and locations, increasing market share can increase profit margins, so it can make sense to pick up a less lucrative contract.

But no more picking up bad contracts for the sake of growth.

Probably trim some of the admin fat, etc

Trim some admin fat? lol as if. They may replace old chronies with their own tumor implants.

 

[UscGhost]

ASA/CSA would never do this. Nice to see AAEM take up the cause.

ER Doctors Vow to Pursue Case Against Envision Despite Bankruptcy - KFF Health News

The lawyer for an emergency physicians group says its lawsuit against Envision Healthcare should be allowed to proceed even though the company has filed for Chapter 11 protection.

kffhealthnews.org

Long shot.

Corporate practice is everywhere...doubt it will change now

 

[Dr. Rude]

There have been more than a few people in ASA senior leadership th at that worked for the management companies. It is likely a big factor why they won’t take an aggressive stance on the CRNA issue, non competes, medical title appropriation, etc. their company would be seen as “anti-CRNA”.

 

[CubsDynasty]

That fat trimming comes from moving to 4:1 whenever possible and getting rid of the practices that aren’t flush with profit. Admin won’t see any of it lol, maybe they’ll even get fatter as a reward for handling these troubling times.

 

[nimbus]

There have been more than a few people in ASA senior leadership th at that worked for the management companies. It is likely a big factor why they won’t take an aggressive stance on the CRNA issue, non competes, medical title appropriation, etc. their company would be seen as “anti-CRNA”.

Risky to be perceived as “anti-CRNA” nowadays.

“CCI Anesthesia is committed to investing in our most valuable resource—anesthesia providers. Our network of client facilities is constantly growing, and we are actively searching for highly trained and skilled providers. We work exclusively with anesthesiologists and CRNAs, and do not use AAs to fill any of our roles. While we respect the ability of AAs, we choose to work solely with CRNAs due to their ability to work independently in diverse settings ranging from urban to rural areas. Our positions are best suited for experienced professionals who want to practice in a culture where they are encouraged to work at the top of their skillset.”

They also go on and on about saving money on anesthesia by using independent CRNAs.

Clinical Opportunities | CCI Anesthesia

Clinical Colleagues’ success centers around our ability to recruit highly trained and skilled anesthesiologists and anesthetists.

www.ccianesthesia.com

 

[<(^_^)>]

With CRNA salaries skyrocketing and MD salaries increasing (to a lesser extent) and virtually everyone “short” I don’t think any of their strategies will pan out. Surprise billing is over. The golden goose of these AMCs (negotiating a huge unit value) is neutered. Anesthesiology is increasingly a money losing service (like ED/trauma) and I don’t see how they will be able to achieve staffing while taking their cut. Their pitch used to be “we don’t need a subsidy, unlike that private practice group”. Now they also want the same subsidy, try to run as lean as possible staffing-wise to get their cut, and slow down the money making engine of the hospital resulting in them being thrown out.

For a while the AMC playbook worked. With the no surprises act they don’t bring anything to the table anymore, and hospitals are realizing this quickly.

 

[aneftp]

The final question is what exactly did KKR “lose” from this purchase.

In my opinion they lost nothing.

Like a homeowner even if they put 30% down on a 1 million dollar house. I doubt kkr even put down 3 billion of their own money. They probably borrowed 2.5 billion of that 3 billion dolllar down payment. And than borrowed the other 7 billion.

It’s all a game.

So in my opinion. Kkr didn’t have more than 500 million (or less) of their own money in the game. Please any one correct me if I’m wrong I believe I’m correct. All these guys are crooks.

They’re a 2007 Chicago tribune (and others)newspaper sale 8.2 billion dollar purchased. Highly leverage. Guess how much Sam zell actually used of that 8.2 billion purchased. 50 million. That’s it!! Now that’s what you call highly leverage.

“
Zell stepped in April 1 to put together a deal in which he is to gain control in a highly leveraged buyout that will take the company private under an employee stock ownership plan. Since then, the newspaper industry's overall outlook and advertising revenues have weakened, fueling speculation the deal could fall apart under Tribune's increasing debt.

Novosel said the deal is clouded by high costs, unstable credit markets and deteriorating operational performance. He thinks it may be renegotiated, although that would lead to the near-certainty of shareholder lawsuits and other headaches.

Zell declined comment through a spokeswoman Monday. But the growing consensus among experts is that the mogul, who has sunk $250 million into the deal including a $200 million loan, is not walking away from it.”

Tribune Shareholders Approve Sale As Expected, 8.2 Billion Dollar Buyout

CHICAGO, IL - Tribune Co. shareholders overwhelmingly approved the $8.2 billion buyout of the media conglomerate Tuesday, but the transaction still needs financing and federal waivers. Preliminary results indicated 97 percent of those casting votes approved the deal led by billionaire Sam Zell...

www.cleveland19.com

 

[aneftp]

With CRNA salaries skyrocketing and MD salaries increasing (to a lesser extent) and virtually everyone “short” I don’t think any of their strategies will pan out. Surprise billing is over. The golden goose of these AMCs (negotiating a huge unit value) is neutered. Anesthesiology is increasingly a money losing service (like ED/trauma) and I don’t see how they will be able to achieve staffing while taking their cut. Their pitch used to be “we don’t need a subsidy, unlike that private practice group”. Now they also want the same subsidy, try to run as lean as possible staffing-wise to get their cut, and slow down the money making engine of the hospital resulting in them being thrown out.

For a while the AMC playbook worked. With the no surprises act they don’t bring anything to the table anymore, and hospitals are realizing this quickly.

Hospitals are loathe to give more subsidies. But they keep demanding more services.

I was involved in 13 OR cases yesterday before 5pm at level 2 trauma center plus 5 more GI cases.
Only one gi case was considered essential (a food bolus on pediatric patient) only 4 of the OR cases done were really considered urgent (in my opinion)

Hospital is paying me extra. Paying crna’s extra. It’s only 25% commercial 10%-15% uninsured. It’s a money losing operation especially on weekends. But they won’t tell the private surgeons no.

 

[repititionition]

Hospitals are loathe to give more subsidies. But they keep demanding more services.

I was involved in 13 OR cases yesterday before 5pm at level 2 trauma center plus 5 more GI cases.
Only one gi case was considered essential (a food bolus on pediatric patient) only 4 of the OR cases done were really considered urgent (in my opinion)

Hospital is paying me extra. Paying crna’s extra. It’s only 25% commercial 10%-15% uninsured. It’s a money losing operation especially on weekends. But they won’t tell the private surgeons no.

Emergency or urgency does not change the calculus which is driven by facility fees. There are no money-losing operations from the facility’s perspective... at least not at current (even very high) labor rates.

 

[Robotic Wis-Hipple]

Hospitals are loathe to give more subsidies. But they keep demanding more services.

I was involved in 13 OR cases yesterday before 5pm at level 2 trauma center plus 5 more GI cases.
Only one gi case was considered essential (a food bolus on pediatric patient) only 4 of the OR cases done were really considered urgent (in my opinion)

Hospital is paying me extra. Paying crna’s extra. It’s only 25% commercial 10%-15% uninsured. It’s a money losing operation especially on weekends. But they won’t tell the private surgeons no.

Well, it’s a money loser for anesthesia but the hospital makes money on pretty much any OR case, especially if any devices/hardware is used. GI is a throughput issue if not a good private payor/elective procedure as it holds up discharge/LOS.

But yes, hospitals keep wanting more sites covered for the same amount, they want more specialty call without adding money to pay you for that availability, they want more ORs to run on the weekends which adds to the percentage of the group on call/increases call frequency. These idiot business folks can’t understand that isn’t free and nobody wants MORE call frequency for the same money. Delusional.

 

[partydoc]

These idiot business folks can’t understand that isn’t free and nobody wants MORE call frequency for the same money. Delusional.

I think they do, they just don’t care.

 

[DesiredMemberName?]

Of course they want and will push for more service for the same money.

In this market, WE are the idiots if we are caving to these requests.

We should all be seeing increased financial support from the hospital for current services provided to offset reductions in anesthesia reimbursement and inflated labor costs. Any desired expansion of services is just going to cost that much more.

Let them know the price tag, and they can decide whether or not they can afford it.

 

[UscGhost]

Emergency or urgency does not change the calculus which is driven by facility fees. There are no money-losing operations from the facility’s perspective... at least not at current (even very high) labor rates.

Yup.

My hospital gets pissed if the podiatrist wants to do a medi-cal bandage change on the floor. They want those facility fees.

Anesthesia is just a operating cost. Hospitals just don't like to pay for something they didn't have to pay for before. Times changed so they have no choice

 

[USCTrojan11]

Emergency or urgency does not change the calculus which is driven by facility fees. There are no money-losing operations from the facility’s perspective... at least not at current (even very high) labor rates.

This.

Unless you're in a capitation model (you're not for the type of procedures you described), plenty of money is brought in. Would it be more lean and efficient on the week days? Of course, but still large amount of positive cash flow, along with government subsidies/credits/tax breaks for offering essential services to the community.

The subsidies and facility fees more than cover your labor, supplies, meds and hospitalization. The excess goes to c-suite annual bonuses and "foundation" money.

Stop programming yourself to think that only the units that anesthesia bills for should be what you are paid. It's a false screen by admin to make it seem like they are barely making ends meet, while they have an influx of money that easily covers your costs and stipend.

 

[amyl]

I’m hearing grumblings that hospitals are in the red and bankruptcies are inevitable.

 

[aneftp]

I’m hearing grumblings that hospitals are in the red and bankruptcies are inevitable.

What do u mean? Hospitals in general? Are in the red?

It’s rare for a hospital to close down unless it’s indigent. (Rural) or ghetto city hospital (only those get closed down if there is a nearby hospital to pickup the load like Atlanta medical center closed to Grady is one mile away to dump.

 

[repititionition]

I’m hearing grumblings that hospitals are in the red and bankruptcies are inevitable.

rural hospitals, yes. those without access to CAH money, yes.

everyone else (those hospitals that most everyone here are working...), not a chance. These are the hospitals that perpetually demonstrate low/no margins while at the same time (abusing?) their nonprofit status and intentionally drive down margin via year-end “clear the books” bonuses and irrational capital projects that cultivate donor goodwill and fulfill the fantasies of aging C-suite members (ever-larger cancer centers, lobby remodels, etc.).