{
  "study": {
    "slug": "hospitals-low-days-cash-on-hand",
    "title": "Hospitals running out of cash: the days-cash signal, and why most of it is a reporting artifact",
    "standfirst": "Federal HCRIS cost reports let us compute days cash on hand for 5,459 hospitals, but facility-level figures are distorted by system-level cash pooling — so the raw '2,800 hospitals under 30 days' headline is mostly noise. The defensible signal is narrower: 690 hospitals that report thin cash and also run an operating loss.",
    "desk": "financial-distress",
    "article_type": "Original Research",
    "published": "2026-06-04",
    "issue": 52,
    "doi": "10.5072/fonteum/hospitals-low-days-cash-2026",
    "url": "https://fonteum.com/research/hospitals-low-days-cash-on-hand",
    "methodology_version": "hcris-days-cash/v1"
  },
  "data_as_of": "2026-05-24",
  "datasets": [
    {
      "slug": "cms-hospital-compare",
      "name": "CMS Hospital Compare",
      "publisher": "CMS — Hospital quality (Care Compare)",
      "upstream_url": null
    }
  ],
  "key_findings": [
    {
      "number": "690",
      "finding": "hospitals report under 30 days cash on hand AND an operating loss — the defensible distress signal",
      "dataset": "cms-hospital-compare"
    },
    {
      "number": "27",
      "finding": "days — median reported days cash on hand across all 5,459 hospitals, vs a 150–205-day audited benchmark",
      "dataset": "cms-hospital-compare"
    },
    {
      "number": "2,800",
      "finding": "hospitals compute to under 30 days of cash on a raw count — mostly a balance-sheet pooling artifact",
      "dataset": "cms-hospital-compare"
    },
    {
      "number": "1,641",
      "finding": "of the 2,800 hospitals under 30 days cash report under $100,000 in cash (59%) — the tell-tale of a pooling artifact, not insolvency",
      "dataset": "cms-hospital-compare"
    }
  ],
  "faqs": [
    {
      "q": "What is days cash on hand?",
      "a": "Days cash on hand estimates how many days a hospital could cover operating expenses from cash and short-term investments alone. Fonteum computes it from federal HCRIS Worksheet G balance sheets for 5,459 hospitals; the median reported figure is 27 days, against an audited-statement benchmark of 150 to 205 days."
    },
    {
      "q": "Why is the raw \"2,800 hospitals under 30 days\" figure misleading?",
      "a": "Because facility-level cost reports are distorted by system-level cash pooling. Of the 2,800 hospitals that compute to under 30 days, 1,641 (59%) report under $100,000 in cash, and one large system hospital books a $6.6-billion operating expense against just $4,000 of cash. Those are reporting artifacts, not near-insolvency."
    },
    {
      "q": "What is the defensible distress signal?",
      "a": "Fonteum applies a composite screen: credible cash reporting (at least $100,000 on hand), thin liquidity (under 30 days), and an operating loss. 690 hospitals meet all three — about one in five of the 3,676 hospitals that report credible cash balances at all."
    },
    {
      "q": "Where are the distressed hospitals?",
      "a": "New York (63), California (51), and Texas (41) lead by raw count because they have the most hospitals. Relative to their small hospital bases, rural states carry outsized counts — Oklahoma (32), Kansas (26), and Louisiana (23)."
    },
    {
      "q": "Can I reproduce these figures?",
      "a": "Yes. Every figure derives from the cms-hcris-hospital-2552-10 snapshot (frozen 2026-05-24), computing days cash from Worksheet G balance-sheet lines; the exact SQL is published in the reproducibility block below."
    }
  ],
  "citation": {
    "apa": "Fonteum Research. (2026, June 04). Hospitals running out of cash: the days-cash signal, and why most of it is a reporting artifact. Fonteum Research, Issue 52. https://doi.org/10.5072/fonteum/hospitals-low-days-cash-2026",
    "url": "https://fonteum.com/research/hospitals-low-days-cash-on-hand"
  },
  "reproducible_sql": "-- Hospitals Low on Days Cash on Hand — fully reproducible query.\n--\n-- Source:   CMS HCRIS Hospital Cost Reports (form CMS-2552-10), FY2024 vintage.\n-- Snapshot: cms-hcris-hospital-2552-10 / 2026-05-24\n-- Archive:  https://downloads.cms.gov/FILES/HCRIS/HOSP10FY2024.ZIP\n-- SHA-256:  e9552da36dcdcf904c5c4d35ffffe843af5b38afac196ac9db7db101bc8a96a0\n--\n-- Days Cash on Hand (All Sources) — per the American Hospital Directory's\n-- published CMS-2552-10 worksheet reference:\n--   (cash on hand + marketable securities + investments)\n--     / ((total operating expense - depreciation) / 365)\nWITH base AS (\n  SELECT\n    ccn,\n    NULLIF(raw_payload->>'g000000_c1_l1','')::numeric                  AS cash,           -- Wksht G, line 1, col 1\n    COALESCE(NULLIF(raw_payload->>'g000000_c1_l2','')::numeric, 0)\n      + COALESCE(NULLIF(raw_payload->>'g000000_c1_l31','')::numeric, 0) AS investments,   -- G line 2 + line 31\n    NULLIF(raw_payload->>'g300000_c1_l4','')::numeric                  AS total_oper_exp, -- Wksht G-3, line 4, col 1\n    COALESCE(NULLIF(raw_payload->>'a700003_c9_l3','')::numeric, 0)     AS depreciation    -- Wksht A-7 Pt III, line 3, col 9\n  FROM public.hcris_cost_reports_raw\n),\ndcoh AS (\n  SELECT\n    b.ccn,\n    b.cash,\n    365.0 * (b.cash + b.investments) / (b.total_oper_exp - b.depreciation) AS days_cash_on_hand,\n    s.operating_margin_pct,\n    left(b.ccn, 2) AS cms_state_code   -- first two CCN chars = CMS/SSA state code\n  FROM base b\n  JOIN public.hcris_facility_summary s ON s.ccn = b.ccn\n  WHERE b.cash IS NOT NULL\n    AND (b.total_oper_exp - b.depreciation) > 0\n)\nSELECT\n  count(*)                                                                          AS computable,\n  round(percentile_cont(0.5) WITHIN GROUP (ORDER BY days_cash_on_hand)::numeric, 1) AS median_days_cash,\n  -- Naive, ARTIFACT-CONTAMINATED counts (do not headline these):\n  count(*) FILTER (WHERE days_cash_on_hand < 30)                                    AS raw_under_30,\n  count(*) FILTER (WHERE days_cash_on_hand < 30 AND cash < 100000)                  AS raw_under_30_near_zero_cash,\n  -- Composite distress (defensible): credible cash AND operating loss AND low days:\n  count(*) FILTER (WHERE cash >= 100000 AND operating_margin_pct < 0 AND days_cash_on_hand < 15) AS composite_under_15,\n  count(*) FILTER (WHERE cash >= 100000 AND operating_margin_pct < 0 AND days_cash_on_hand < 30) AS composite_under_30,\n  count(*) FILTER (WHERE cash >= 100000 AND operating_margin_pct < 0 AND days_cash_on_hand < 60) AS composite_under_60\nFROM dcoh;",
  "license": "U.S. Government Works (federal sources; 17 U.S.C. §105)",
  "generated_by": "Fonteum — https://fonteum.com",
  "notes": "Aggregate, source-traced figures frozen to the snapshot above. Reproduce by running reproducible_sql against the cited federal dataset; no per-entity records are included."
}