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Stanford Health Care

Financial Analysis Report

Mustafa Mahmood

Maryam Hussain A Aldubaisi

Submitted

To

Dr Sung W. Choi

Pennsylvania State University Harrisburg Campus

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Table of contents

Title Page numbers


Objective/ Introduction 3-4

Interpretation of organization’s 5-7

Statements of Cash flow

Profitability ratios 8-9

Liquidity Ratios 9

Working Capital Ratios 10

Solvency Ratios 10-11

Organizations Financial condition 11-12

Evaluation

Recommendations for higher 12

management

Appendix 13-25

References 25

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Objective:

This study analyzes financial statements of Stanford Health Care for the years 2016-18, by

using key financial ratios and determine their financial health, performance and position.

Introduction

Stanford Health Care (SHC) founded in 1959, is a renowned university-owned, not for profit

academic medical center which is delivering world-class health care. Stanford is providing

tertiary and quaternary treatments for complex and rare disease and disorders and primary

care for their community. They have six centers of excellence: Cancer Center, Heart Center,

Neuroscience Center, Orthopedic Surgery and Sports Medicine, Surgical Services Program

and Transplantation Programs.

It is one of the US best organizations to provide health care facilities. In 2017 the hospital

was ranked 9th among 5462 medical centers’ in the US. In 2018 Stanford ranked second in

US in the specialty of otolaryngology (head and neck surgery). Their extraordinary services

have also been recognized by Magnet Designation three consecutive times as well as many

other awards, such as the Leapfrog Group, and HIMSS Analytics. ("Patient Experience

Case Study - Stanford Health Care - The Beryl Institute - Improving the Patient

Experience", 2019).

SHC produces clinical innovation across its inpatient services, specialty health centers,

physician offices, virtual care offerings and health plan programs. Being a nonprofit

organization, they maintain a strong commitment to the health of its community members and

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dedicates considerable resources to support their benefit program ("Community

Partnerships", 2019), eg during year 2016-17, SHC invested nearly $362 million (2019) in

services and activities to improve the health of the communities serves. Their community

services are wide ranging that ensure health care access to the elderly and indigent patients

and produce highly valuable service programs to improve the health status of the community.

Mission Statement:

• To Care

• To Educate

• To Discover

Vision Statement:

Healing humanity through science and compassion, one patient at a time (2019).

Community Served:

Although SHC cares for patients from throughout California, as well as nationally and

internationally, a majority of its patients, nearly 65 percent, live in San Mateo and Santa

Clara counties (2019).

SHC community benefit activities fall into three major categories (2019):

1. Benefits for vulnerable populations, 78%.

2. Benefits for the community at large, 1%

3. Health research, education, and training programs, 21%

SHC operates multiple outpatient facilities and physical practices throughout the California

Bay Area and beyond and operate with more than 6,000 employees in 300 facilities

As a not-for-profit organization, Stanford Health Care is investing their surpluses in operating

innovative services, facilities, and community health programs. Every three years they carry

out assessment of the situation to identify compelling health needs affecting community and

work out strategies to improve the health of community members.

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Interpretation of Organization’s statements of cash flows

Cash flow ratios are the comparisons of cash flow statement components with other

components of cash flow statement and other components of financial statement. These cash

flow ratios are more reliable indicators of liquidity than balance sheet ratios such as current

and quick ratio. Lenders and rating agencies have also long used these ratios for evaluation of

risk. The information contained on a cash flow statement stresses the existing differences

between the operating profits of a firm and the decrease or increase in bank/cash balance over

a similar accounting period. Due to this, a cash flow statement is important to shareholders,

suppliers, creditors as well as other stakeholders to a business entity (Knechel et al, 2007).

 Cash flow margin ratio:

CASH FLOW FROM OPERATIONS/ SALES (CFO) *

100

2018 694,704/4910,546 * 100 14%

2017 335,336 /4454,401* 100 7.50%

This ratio tells us how much cash is obtained on every dollar of sales made. Though cash

flow margin ratio of 14% in the year 2018 do not appear good, yet has improved significantly

if compared with year 2017 i.e. It has almost doubled in year 2018 comparing with the

previous year.

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 Current liability coverage ratio:

CFO/ CURRENT LIABILITIES

2018 694,704/1,089,736 0.63

2017 335,336/1,075,625 0.31

This ratio is known to be a better indicator of current liability as compared to current ratio

and quick ratio and reveals how well the company is handling its current liabilities. Current

year ratio of 0.63 is lesser than one, which means that for every dollar of current liability, the

company has to pay 63 cents.

By looking over two-year trend ratio, we conclude that the company has improved by 103%.

 Cash generating power ratio:

CFO/CFO + CASH FLOW FROM INVESTING + CASH

FLOW FROM FINANCING

2018 694,704/694,704 + (990691) + 238,134 -12

2017 335,336/335,336 + (428,895) + 113,208 17

Stanford has strong CFO generation power in comparison to cash flow from investing and

financing which is a very positive indication. In the year 2018, negative ratio shows that the

overall net cash flow during the year was negative due to huge cash outflow in investing

activities.

 Asset efficiency ratio:

CFO/ TOTAL ASSETS*100

2018 694,704/7214,849 * 100 9.60%

2017 335,336 /6,229,612* 100 5.40%

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This ratio is similar to return on assets (ROA) but instead of using net income the ratio uses

CFO. This ratio tells us how well company uses its assets to generate cash flows. In 2018

asset efficiency ratio is improved by 77% over the year.

 Long term debt coverage ratio:

CFO/ Long term debts

2018 694,704/2,163,929 0.32

2017 335,336/1,649,419 0.2

Looking over the year 2018 ratio of 0.32 we can conclude that for every dollar we have 32

cents to settle liabilities.

The ratio has improved by 60% over the year 2017.

External financing index ratio:

Cash flow from financing/ CFO*100

2018 238,134/694,704*100 34%

2017 113,208/335,336*100 34%

This ratio shows how much Stanford is dependent on financing comparing to operational

cash flows.

The lower the number, the lower would be dependence on financing for Stanford.

Ratio has remained stable over the years.

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Key Ratios using balance sheet and income statement:

Profitability ratios:

Profit margin ratio:

(Change in unrestricted net assets/ Total unrestricted revenue and

support) * 100

2018 (410952/4910546) * 100 8.37%

2017 (424003/4454401) * 100 9.50%

As Stanford is non-profit organization its basic objective is not to prioritize profit. Yet it

would like to have positive profit margin to indicate that the organization is doing well. But

an excessive margin would indicate that dues are too high which would rather discourage the

donors. Although, the margin has decreased over the year, yet 8.37% of profit margin in year

2018 seems quite normal.

Operating reserve ratio:

net assets without restriction/ Annual expense –

depreciation

8.88
2018 3304125/4589887-176742 * 12
months

8.52
2017 2893173/4220519-154686 *12
months

High operating reserve ratio indicates that organization is in good financial shape. This ratio

indicates that how many months Stanford can sustain without any revenue. Over the years the

ratio has remained stable and current year eight-month figure is a positive indication for

Stanford.

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Return on net asset ratio:

changes in net assets/ Total net assets*100

10.40
2018 (410952/3961184*100
%

12.10
2017 (424003/3504568) *100
%

RONA is financial performance measure which shows how well the company is using its net

assets to generate income. Higher the ratio better the performance. This ratio has decreased

by 14% over the year that is from 12.1% to 10.4% which indicates poor use of resources

compared to previous years.

Liquidity Ratios:

Current ratio:

Currents assets/ Currents liabilities

2018 1857453/1089736 1.7

2017 1724575/1075625 1.6

Current ratio is widely used. This ratio indicates that the organization has more currents

assets to settle current liabilities. A ratio of 1.7 this year is very good indicator regarding

company’s strong liquidity which has improved over the year.

Quick ratio:

(currents assets – inventory)/ Current liabilities

2018 (1857453-58884)/ 1089736 1.65

2017 (1724575-56559)/ 1075625 1.55

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It is similar to current ratio minus inventory. Since Stanford hold minimum inventory due to

its being in service sector, the quick ratio is similar to the current ratio.

Working Capital Ratios:

Account receivables turnover days:

(receivables/ sales) *365

2018 (623077/4910546) *365 46 days

2017 (610734/4454401) *365 50 days

This ratio shows how many days Stanford took to collect its receivables. Collection period of

46 days in the year 2018 shows an improvement vis-a-vis 50 days in the year 2017.

Collection period of 30 to 60 days is considered as normal which can be improved further by

allowing early settled discounts, better credit control and efficient collection mechanism.

Days of cash on hand

cash+ marketable securities / (Expenses – depreciation – bad debts)

* 365

2018 (652256+391314/4589887-176742-57437) *365 87 Days

2017 (710109+233533/4220519-154686-77004) *365 86 Days

Ratio explains how much cash an organization hold to cover its expenses and its calculated in

days. Stanford hold enough cash to cover expenses of almost 87 days. Ratio remains stable

over the year.

Solvency Ratios:

Debt to Asset Ratio:

Total debts/ Total assets*100

2018 2163929/7214849 * 100 29%

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2017 1649419/6229612 * 100 26%

Debt to asset ratio is a leverage ratio which shows how many assets are financed from debt.

29% figure seems fine for this organization with sound operating reserve ratio. It has

however marginally increased over the year.

Debt to Net Asset ratio:

Total debts/ Total net assets*100

2018 (2163929/3,961,184) * 100 55%

2017 (1649419/3,504,568) * 100 47%

Being a not for profit organisation Stanford doesn’t have equity. Net assets have been used to

calculate the gearing of Stanford. 55% debt to net asset ratio in year 2018 do not sound good

as Stanford is relying on debt more the 50% of the net assets it has. Also, the ratio has

increased by 17% over the year which also is not good sign.

Evaluation of the organization’s financial condition:

Strengths: Stanford is financially stable organisation having strong cash position and asset

base. Its cash flows from operation are almost doubled over the year, which show financial

efficiency and management competence. Stanford asset base has been increased by one

billion comparing to increase in liabilities of approximately $0.5 billion. Stanford income

from operation has shown great improvement due to professional competence and operational

efficiency

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Weakness: Stanford holds huge amount of unutilised cash stack which is more than half a

billion dollars. This cash has an opportunity cost and must be utilised in an appropriate

method not at the expense of cash running out situation. The debt base is piling up which

makes the organisation riskier and might lead to decrease its credit rating.

As a non-profit organisation Stanford prime objective is not to make profit. Margins and

return on assets have fallen but still profitability ratios look good with return on asset above

10%. Stanford liquidity and working capital ratios have also been improved marginally and

liquidity position is quite good shape. The organisation seems heavily geared but looking at

cash flow position it does not pose any threat.

Recommendations for Higher Management:

Stanford is a financially sound company; all credit goes to competent management.

However, there is always a room for improvement.

As a non-profit organisation, the unutilised cash should either be utilised in short term

investment or in operational activities. Holding such a huge cash may make donors rethink of

their further donations as such they see their donations piled up, rather being spent on the

welfare. Management should also try not to put too much reliance over debt rather on

donations which are interest free.

Being non-profit organisation management should focus on delivering best care in affordable

prices, a huge profit from operation might not be in line with their mission statement.

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Appendix

Appendix A

Stanford Health Care

Consolidated Balance Sheets

August 31, 2018 and 2017

(in thousands of dollars)

2018 2017

$ $

Assets

Current assets:

Cash and cash equivalents 652,256 710,109

Short term investments 391,314 233,533

Patient accounts receivable 623077 610734

Other receivables 79036 71112

Inventories 58,884 56,559

Prepaid expenses and other 52,886 42,528

Total current assets 1,857,453 1,724,575

Investments 509,781 111,664

Investments at equity 80,989 66,255

Investments in University managed pools 1,400,839 1,287,193

Assets limited as to use, held by trustee 58,134 58,134

Property and equipment, net 3,279,048 2,869,346

Other assets 86,739 112,445

Total assets 7,214,849 6,229,612

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Liabilities and Net Assets

Current liabilities:

Accounts payable and accrued liabilities 449,192 307,899

Accrued salaries and related benefits 209,490 255,759

Due to related parties 98,942 71,429

Third-party pay or settlements 34,474 18,149

Current portion of long-term debt 14,505 13,335

Revolving line of credit 135,000

Debt subject to short-term remarketing arrangements 228,200 228,200

Self-insurance reserves and other 54,933 45,854

Total current liabilities 1,089,736 1,075,625

Self-insurance reserves 139,841 130,816

swap liabilities 182,527 245,966

Other long-term liabilities 122,944 31,363

Pension liability 6,650 51,745

Long-term debt, net of current portion 1,711,967 1,189,529

Total liabilities 3,253,665 2,725,044

Net assets:

Unrestricted:

Stanford Health Care 3,285,398 2,871,113

Non controlling interests 18,727 22,060

Total unrestricted 3,304,125 2,893,173

Temporarily restricted 648,826 603,251

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Permanently restricted 8,233 8,144

Total net assets 3,961,184 3,504,568

Total liabilities and net assets 7,214,849 6,229,612

Appendix B

Stanford Health Care

Consolidated Statements of Operations and Changes in Net Assets

Years Ended August 31, 2018 and 2017

(in thousands of dollars)

2018 2017

Operating revenues:

Net patient service revenue 4,735,366 4,311,530

Provision for doubtful accounts -57,437 -77,004

Net patient service revenue less provision for doubtful


4,677,929
accounts 4,234,526

Premium revenue 92,654 80,647

Other revenue 135,597 129,324

Net assets released from restrictions used for operations 4,366 9,904

Total operating revenues 4,910,546 4,454,401

Operating expenses:

Salaries and benefits 2,091,260 1,986,360

Professional services Supplies 46,146 42,851

Supplies 667,379 586,056

Purchased services 1,216,992 1,136,020

Depreciation and amortization 176,742 154,686

Interest 35,434 43,643

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Other 477,661 384,354

Expense recoveries from related parties -121,727 -113,451

Total operating expenses 4,589,887 4,220,519

Income from operations 320,659 233,882

Interest and investment income 31,122 15,325

Earnings on equity method investments 7,048 5,114

Increase in value of University managed pools 110,984 144,829

Loss on extinguishment of debt -47,613

Interest rate swaps mark to market adjustments 48,043 85,368

Excess of revenues over expenses 470,243 484,518

Other changes in unrestricted net assets:

Transfer to Stanford University, net -98,183 -69,376

Transfer to Lucile Salter Packard Children's Hospital 2,068

Change in net unrealized gains on investments 9,438 1,058

Net assets released from restrictions used for:

Purchase of property and equipment 309 1,320

Change in pension and postretirement liability 28,277 6,182

Non-controlling capital contributions (distributions) -1200 301

Increase in unrestricted net assets 410952 424003

Changes in temporarily restricted net assets:

Transfer from Stanford University Contributions and other 2,177 2,748

Contributions and other 44,894 28,541

Investment income 712 4,662

Gains on University managed pools 2,467 1,438

Net assets released from restrictions used for:

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Operations -4,366 -9,904

Purchase of property and equipment -309 -1,320

Increase in temporarily restricted net assets 45,575 26,165

Changes in permanently restricted net assets: Contributions

Contributions 89 250

Increase in permanently restricted net assets 89 250

Increase (decrease) in net assets Net assets, beginning of year 456,616 450,418

beginning of year 3,504,568 3,054,150

Net assets, end of year 3,961,184 3,504,568

Appendix C

Stanford Health Care

Consolidated Statements of Cash Flows

Years Ended August 31, 2018 and 2017

(in thousands of dollars)

2018 2017

Cash flows from operating activities:

Change in Stanford Health Care net assets 459,949 448,491

Change in non controlling interests -3,333 1,927

Total change in net assets 456,616 450,418

Adjustments to reconcile change in net assets to

net cash provided by operating activities:

Depreciation and amortization 174,665 152,840

Provision for doubtful accounts 57,437 77,004

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Change in fair value of interest rate swaps -63,439 -85,368

Increase in value of University managed pools -110,984 -144,829

Unrealized gains on investments -10,700 -5,138

Realized gains on investments -22

(Excess) deficit of income of equity method investees over distributions -2,047 -12,154

Contributions received for long lived assets or endowment and net equity -37,958

Net equity transfers to/from related parties


93,938
44,639

Changes in operating assets and liabilities:

Patient accounts receivable -69,780 -127,805

Due to related parties 4,274 -24,877

Other receivables, inventory, other assets, prepaid expenses and other s 1,108 4,174

Accounts payable, accrued liabilities and pension liabilities 89,663 -22,131

Accrued salaries and related benefits -46,269 18,940

Third-party pay or settlements 16,325 -4,799

Self-insurance reserves 18,014 14,444

Cash provided by operating activities 694,704 335,336

Cash flows from investing activities:

Purchases of investments -593,592 -204,822

Sales of investments 47,143 68,350

Purchases of investments at equity -10,843 -12,752

Purchases of investments in University managed pools -1,524 -1,764

Sales of investments in University managed pools 119 179,989

Decrease in assets limited as to use and other 58,134 177,654

Purchases of property and equipment -474,735 -635,550

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Cash used in investing activities -990,691 -428,895

Cash flows from financing activities:

Borrowing on revolver -135,000 135,000

Costs of issuance of debt -6783 -71

Payment of long-term debt and capital lease obligations -544,331 -18,708

55899
40,747
Contributions received for long lived assets or endowment and net equity

transfers to/from related parties -70,699 -3,013

Cash provided by (used in) financing activities 238,134 113,208

Net increase in cash and cash equivalents 57,853 19,649

Cash and cash equivalents, beginning of year 710,109 690,460

Cash and cash equivalents, end of year 652,256 710,109

Appendix

Appendix D

Stanford Health Care

Consolidated Balance Sheets

August 31, 2017 and 2016

(in thousands of dollars)

2017 2016

$ $

Assets

Current assets:

Cash and cash equivalents 710,109 690,460

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Short term investments 233,533 103,627

Patient accounts receivable 610734 559,933

Other receivables 71112 92,961

Inventories 56,559 50,016

Prepaid expenses and other 42,528 36,273

Total current assets 1,724,575 1,533,270

Investments 111,664 104,038

Investments at equity 66,255 41,609

Investments in University managed pools 1,287,193 1,316,489

Assets limited as to use, held by trustee 58,134 235,788

Property and equipment, net 2,869,346 2,401,880

Other assets 112,445 124,263

Total assets 6,229,612 5,757,337

Liabilities and Net Assets

Current liabilities:

Accounts payable and accrued liabilities 307,899 335,995

Accrued salaries and related benefits 255,759 236,819

Due to related parties 71,429 61,308

Third-party pay or settlements 18,149 22,948

Current portion of long-term debt 13,335 13,756

Revolving line of credit 135,000

Debt subject to short-term remarketing arrangements 228,200 228,200

Self-insurance reserves and other 45,854 43,232

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Total current liabilities 1,075,625 942,258

Self-insurance reserves 130,816 118,994

Other long-term liabilities 277,329 355,683

Pension liability 51,745 65,463

Long-term debt, net of current portion 1,189,529 1,220,789

Total liabilities 2,725,044 2,703,187

Net assets:

Unrestricted:

Stanford Health Care 2,871,113 2,449,037

Non-controlling interests 22,060 20,133

Total unrestricted 2,893,173 2,469,170

Temporarily restricted 603,251 577,086

Permanently restricted 8,144 7,894

Total net assets 3,504,568 3,054,150

Total liabilities and net assets 6,229,612 5,757,337

Appendix E

Stanford Health Care

Consolidated Statements of Operations and Changes in Net Assets

Years Ended August 31, 2017 and 2016

(in thousands of dollars)

2017 2016

Operating revenues:

Net patient service revenue 4,311,530 4,019,285

Provision for doubtful accounts -77,004 -126,280

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Net patient service revenue less provision for doubtful

accounts 4,234,526 3,893,005

Premium revenue 80,647 72,292

Other revenue 129,324 122,996

Net assets released from restrictions used for operations 9,904 9,372

Total operating revenues 4,454,401 4,097,665

Operating expenses:

Salaries and benefits 1,986,360 1,850,124

Professional services Supplies 42,851 49,846

Supplies 586,056 531,130

Purchased services 1,136,020 1,058,182

Depreciation and amortization 154,686 136,442

Interest 43,643 39,661

Other 384,354 389,199

Expense recoveries from related parties -113,451 -104,965

Total operating expenses 4,220,519 3,949,619

Income from operations 233,882 148,046

Interest and investment income 15,325 13,635

Earnings on equity method investments 5,114

Increase in value of University managed pools 144,829 24,181

Interest rate swaps mark to market adjustments 85,368 -115,958

Excess of revenues over expenses 484,518 69,904

Other changes in unrestricted net assets:

Transfer to Stanford University, net -69,376 -88,944

Transfer to Lucile Salter Packard Children's Hospital -3,300

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Change in net unrealized gains on investments 1,058 1,245

Net assets released from restrictions used for:

Purchase of property and equipment 1,320 973

Change in pension and postretirement liability 6,182 -80

Non-controlling capital contributions (distributions) 301 -1,000

Increase (decrease) in unrestricted net assets 424,003 -21,202

Changes in temporarily restricted net assets:

Transfer from Stanford University Contributions and other 2,748 2,645

Contributions and other 28,541 20717

Investment income 4,662 744

Gains on University managed pools 1,438 1683

Net assets released from restrictions used for:

Operations -9,904 -9,372

Purchase of property and equipment -1,320 -973

Increase in temporarily restricted net assets 26,165 1544

Changes in permanently restricted net assets: Contributions

Contributions 250 200

Increase in permanently restricted net assets 250 200

Increase (decrease) in net assets Net assets, beginning of year 450,418 -5,558

beginning of year 3,054,150 3,059,708

Net assets, end of year 3,504,568 3,054,150

Appendix F

Stanford Health Care

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Consolidated Statements of Cash Flows

Years Ended August 31, 2017 and 2016

(in thousands of dollars)

2017 2016

Cash flows from operating activities:

Change in Stanford Health Care net assets 448,491 -2,712

Change in non-controlling interests 1,927 -2,846

Total change in net assets 450,418 -5,558

Adjustments to reconcile change in net assets to

net cash provided by operating activities:

Depreciation and amortization 152,840 134,502

Provision for doubtful accounts 77,004 126,280

Change in fair value of interest rate swaps -85,368 115,958

Increase in value of University managed pools -144,829 -24,181

Unrealized gains on investments -5,138 -1,712

Realized gains on investments -22

(Excess) deficit of income of equity method investees over distributions -12,154 3,101

Contributions received for long lived assets or endowment and net equity

transfers to/from related parties Changes in operating assets and

liabilities: 44,639 79,767

Changes in operating assets and liabilities:

Patient accounts receivable -127,805 -135,492

Due to related parties -24,877 474

Other receivables, inventory, other assets, prepaid expenses and other s 4,174 -34,759

Accounts payable, accrued liabilities and pension liabilities -22,131 82,724

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Accrued salaries and related benefits 18,940 33,960

Third-party pay or settlements -4,799 13,930

Self-insurance reserves 14,444 6,944

Cash provided by operating activities 335,336 395,938

Cash flows from investing activities:

Purchases of investments -204,822 -59,290

Sales of investments 68,350 67,052

Purchases of investments at equity -12,752 -13,427

Purchases of investments in University managed pools -1,764 -1,729

Sales of investments in University managed pools 179,989 150,240

Decrease in assets limited as to use and other 177,654 344,913

Purchases of property and equipment -635,550 -619,570

Cash used in investing activities -428,895 -131,811

Cash flows from financing activities:

Borrowing on revolver 135,000

Costs of issuance of debt -71

Payment of long-term debt and capital lease obligations -18,708 -15,951

Contributions received for long lived assets or endowment and net equity

transfers to/from related parties -3,013 -33,393

Cash provided by (used in) financing activities 113,208 -49,344

Net increase in cash and cash equivalents 19,649 214,783

Cash and cash equivalents, beginning of year 690,460 475,677

Cash and cash equivalents, end of year 710,109 690,460

References:

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Community Partnerships. (2019). Retrieved from

https://stanfordhealthcare.org/about-us/community-partnerships.html

Patient Experience Case Study - Stanford Health Care - The Beryl Institute - Improving the

Patient Experience. (2019). Retrieved from

https://www.theberylinstitute.org/page/CASE0417

(2019)[Ebook].Retrieved from

https://oshpd.ca.gov/ml/v1/resources/document?rs:path=/Data-And-Reports/Community-

Benefit-Plans/2016/Stanford-University-Hospital-CBP-2016.pdf

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