# Hospital Financial & Regulatory Deep-Dive — Balance Sheet, Charity Care, Cost Centers, Penalties

**Audience:** hospital finance/strategy teams, healthcare consultants, medical device and pharma sales targeting, labor/staffing platforms, credit and municipal-bond analysts covering nonprofit hospitals, health policy researchers.

**What this is.** A hospital-level financial and regulatory profile built entirely from public CMS and Census filings: full balance sheet, charity care and bad debt, per-cost-center charges and staffing costs, Medicare payment penalties (readmissions and DSH), case mix index, service-line availability, and clinical trial activity. Every figure traces back to a specific cost-report worksheet line or federal dataset — no proprietary "black box" adjustments.

## What's in (shipped)

| Source | What it gives us | Scope |
|---|---|---|
| **HCRIS Worksheet G (Balance Sheet)** | Full current/fixed/other asset detail, current/long-term liability detail, fund balance, and derived current/quick/debt-to-equity ratios. | Every hospital filing a Medicare cost report, FY2018–2025 |
| **HCRIS Worksheet S-10 (Uncompensated Care)** | Charity care charges and costs, bad debt expense, non-Medicare bad debt, total uncompensated/unreimbursed care cost. | S-10 reporting was phased in — available from roughly FY2023 onward |
| **HCRIS Worksheets A + C Part I (Cost Centers)** | Charges, total costs, and salary/non-salary split for ~20 named cost centers (Operating Room, ICU, Laboratory, Radiology, Pharmacy-charged supplies, and more), plus every other reported cost-center line. | Every hospital filing a cost report, FY2018–2025 |
| **HCRIS Worksheet E Part A (DSH)** | Medicare Disproportionate Share Hospital patient percentage and payment amount. | Every hospital filing a cost report, FY2018–2025 |
| **CMS HRRP Supplemental Data Files** | Payment adjustment factor and per-condition excess readmission ratios (AMI, COPD, heart failure, pneumonia, CABG, hip/knee replacement) vs. peer-group medians. | FY2021–2026 |
| **CMS IPPS Impact File** | Case Mix Index (current MS-DRG grouper version), wage index, DSH patient percentage. | FY2023–2026 |
| **CMS Provider of Services (POS) file** | ~50 curated clinical service-line availability flags, accreditation agency and dates, medical school affiliation/teaching status. | All hospitals, quarterly |
| **Census Bureau CBSA population estimates** | Metro/micro area population with year-over-year growth. | 2020–2025, ~925 CBSAs |
| **ClinicalTrials.gov** | Trials with a matched site at the facility: sponsor, phase, status, therapeutic area, and matched investigators. | ~194K US-located studies |

## API surface

| Endpoint | What it returns |
|---|---|
| `GET /cost-reports/{ccn}` | Cost report summary — now includes operating income, other income (previously conflated with net income), total salaries, Medicare/Medicaid days and discharges, and DSH percentage/payment. |
| `GET /cost-reports/{ccn}/balance-sheet` | Full balance sheet history with current ratio, quick ratio, and debt-to-equity ratio computed per fiscal year. |
| `GET /cost-reports/{ccn}/charity-care` | Charity care charges/costs, bad debt, and total uncompensated care history. |
| `GET /cost-reports/{ccn}/cost-centers` | Charges, total costs, and salary/non-salary split for every reported cost center, latest year or a specified fiscal year end. |
| `GET /vbc/hrrp/{ccn}` | HRRP payment adjustment factor history by fiscal year. |
| `GET /vbc/hrrp/{ccn}/measures` | Per-condition excess readmission ratio detail. |
| `GET /vbc/hrrp` | Search/rank hospitals by HRRP penalty severity. |
| `GET /hospitals/{ccn}/case-mix-index` | CMI, wage index, and DSH percentage history from the IPPS Impact File. |
| `GET /hospitals/{ccn}/services` | Service-line availability (provided/not provided) from the POS file. |
| `GET /hospitals/{ccn}` | Now includes compact `case_mix_index` and `cbsa_population` blocks. |
| `GET /market-intelligence/cbsa/{cbsa_code}/population` | CBSA population history with year-over-year growth. |
| `GET /hospitals/{ccn}/clinical-trials` | Clinical trials with a matched site at this facility, rolled up by status and phase. |
| `GET /clinical-trials`, `/clinical-trials/{nct_id}` | Search and detail for any US-located clinical trial. |
| `GET /provider/{npi}/clinical-trials` | Trials where a provider is listed as an investigator. |

## Methodology notes worth knowing

- **HRRP `payment_reduction_pct`** is always derived as `(1 - payment_adjustment_factor) * 100`, not read from CMS's own "payment reduction percentage" column — that column's unit is inconsistent across fiscal years in the source files (a percent-as-number convention some years, a raw fraction in others).
- **Case Mix Index** is always resolved to the current MS-DRG grouper version for a given fiscal year (CMS increments the grouper most years) — comparable across years without a schema change, and distinct from proprietary vendor CMI figures that may use a different claims vintage.
- **Cost-center names** are populated only where confidently identified against the standard CMS 2552-10 line structure; unlabeled lines are still captured with their raw line number rather than dropped.
- **Accreditation agency and medical school affiliation labels** were derived empirically (cross-referencing known accreditor market share and teaching-hospital distributions) rather than from an official CMS crosswalk, which wasn't publicly accessible at implementation time. Codes without confident corroboration are stored as raw values, not guessed labels.
- **Clinical trial site/investigator matching** is deliberately conservative — a normalized name + location match accepted only when it resolves to exactly one candidate. Matched counts are a floor, not a ceiling.

## How this is different from incumbents

Vendors that sell hospital financial profiles typically license the same underlying HCRIS cost-report data and present it as a proprietary product without exposing the worksheet-level detail or the derivation. Ours cites the worksheet (G, S-10, A, C, E) behind every figure, so a customer's own finance or audit team can trace a number back to the filing.

## Use cases

**Hospital finance benchmarking.** Compare a target hospital's current ratio, charity-care burden, and cost-per-service-line against peers in the same CBSA.

**Medical device and pharma sales targeting.** Cross-reference service-line availability (`/hospitals/{ccn}/services`) with cost-center spend (`/cost-reports/{ccn}/cost-centers`) to find hospitals investing in a given specialty.

**Credit and municipal-bond analysis.** Balance sheet ratios and HRRP/DSH payment exposure feed directly into nonprofit hospital credit assessments.

**Clinical trial site scouting.** `/hospitals/{ccn}/clinical-trials` surfaces a facility's trial history by therapeutic area and sponsor — useful for CROs assessing site capability.

**Staffing and labor market analysis.** Total salaries and cost-center-level salary/non-salary splits (`/cost-reports/{ccn}/cost-centers`) benchmark a hospital's labor cost structure.