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Amid shifting perceptions of healthcare expertise, board and C-suite leaders must define the basic principles of their organization and its role in medicine, patient care and public health and consider how they will make decisions when these principles might conflict with current perceptions.

The answer to “why weren’t we downgraded” is multifaceted and will depend on each hospital’s circumstances. But there are often three factors at play, including rating tolerance, the role of medians and effective messaging.

As health systems face growing pressure to lower costs, increase market share and run more efficiently, one thing is clear — the strength of their ambulatory care portfolio is quickly becoming a key differentiator.

The healthcare payment landscape continues to face uncertainty as support grows for additional “site neutrality” in reimbursement, with the policy goal of reducing or eliminating payment differentials between hospital-based outpatient departments (HOPDs) and freestanding physician offices or ambulatory care sites for the same services.

Balance sheet strength has buffered consumers and businesses from some of the restrictive shock of higher rates. With a relatively brittle revenue model in healthcare, the focus becomes whether, when, and how to restructure operations as balance sheets are spent down.