Credit agencies affirm 'A' rating for Dartmouth-Hitchcock, upgrade outlook

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Credit agencies affirm 'A' rating for Dartmouth-Hitchcock, upgrade outlook

Tue, 01/30/2018 - 11:57am -- tim

Vermont Business Magazine Two major credit rating agencies have affirmed their “A” rating for Dartmouth-Hitchcock Health (D-HH), with an upgrade of the credit outlook from both services. FitchRatings (Fitch) has affirmed its “A” rating, and has upgraded its credit outlook to “positive” for D-HH. Meanwhile, Standard & Poor’s has affirmed its “A” rating and improved its outlook for D-HH from “negative” to “stable.”

The ratings were released last week. Fitch noted D-HH’s resilience in the wake of weaker-than-expected financial results in Fiscal Year 2016 and the health system’s “marked improvement” over the last year. According to Fitch, “[t]he A rating and Positive Outlook reflect Fitch’s expectation that D-HH will continue to improve upon the results of its Performance Improvement Plan [and] … continue to demonstrate strong cost management.”

S&P noted D-HH’s “dramatically” improved financial performance over the last year, adding that “[t]he ‘A’ rating reflects D-HH’s robust enterprise profile serving as both the sole academic medical center and major safety net provider of care in New Hampshire, along with its expansive community physician presence strategically located across the state of New Hampshire and Southern Vermont.”

News releases from both Fitch and S&P are below.

“Dartmouth-Hitchcock Health is very pleased to have received a strong affirmation of our ‘A’ rating from both Fitch and S&P Global Ratings,” said D-HH CEO and President Dr. Joanne Conroy. “We believe it is an acknowledgement of the diligent and focused efforts that the organization undertook over the past 18 months, ensuring our stability as well as remaining steadfast in Dartmouth-Hitchcock Health’s commitment to always provide high-quality patient care in modern facilities throughout New Hampshire and Vermont.”

D-HH anticipates that it will issue up to $700 million in bonds to refinance the majority of its system-wide debt and acquire new money for capital projects.  The issuance will allow D-HH to lock in historically low long-term interest rates, among other benefits.  The bondswill be issued across three different bond market segments: the tax-exempt bond market, the municipal taxable market and the corporate taxable market.

Dartmouth-Hitchcock Health is the parent organization of a regionally distributed academic health system serving patients in New Hampshire and Vermont, as well as elsewhere in New England.  D-HH provides acute, tertiary and quaternary care hospital services, primary care, and multi-specialty ambulatory clinical services to a total population of approximately 1.9 million in its service area. The System is anchored by Dartmouth-Hitchcock Medical Center, an academic medical center located in Lebanon, New Hampshire, that is comprised of Mary Hitchcock Memorial Hospital, a 396-bed teaching hospital and Level 1 Trauma Center for adult and pediatric patients, and the Lebanon division of the Dartmouth-Hitchcock Clinic, a large multi-specialty physician group practice with sites throughout New Hampshire and southern Vermont.  The system also includes Cheshire Medical Center, New London Hospital, and Alice Peck Day Memorial Hospital in New Hampshire, Mt. Ascutney Hospital and Health Center in Vermont, and the Visiting Nurse Association and Hospice of Vermont and New Hampshire. 

DARTMOUTH-HITCHCOCK (D-H) is a nonprofit academic health system serving communities in northern New England. D-H provides access to more than 1,000 primary care doctors and specialists in almost every area of medicine at Dartmouth-Hitchcock Medical Center; theNorris Cotton Cancer Center, the Children’s Hospital at Dartmouth-Hitchcock, four affiliate hospitals, 24 ambulatory clinics and through the Visiting Nurse and Hospice for VT and NH. The D-H system trains nearly 400 residents and fellows annually, and performs world-classresearch, in partnership with the Audrey and Theodor Geisel School of Medicine at Dartmouth and the White River Junction VA Medical Center.

Source: LEBANON, NH – D-HH 1.29.2018

Dartmouth-Hitchcock Obligated Group Bond
Rating Outlook Revised To Stable From Neg On
Improved Financial Performance
Primary Credit Analyst:
Jennifer J Soule, Boston (1) 617-530-8313; jennifer.soule@spglobal.com
Secondary Contact:
Anne E Cosgrove, New York (1) 212-438-8202; anne.cosgrove@spglobal.com

BOSTON (S&P Global Ratings) Jan. 24, 2018--S&P Global Ratings revised its
outlook to stable from negative and affirmed its 'A' rating on New Hampshire
Health and Education Facilities Authority's existing debt issued for the
Dartmouth-Hitchcock Obligated Group. At the same time, S&P Global Ratings
assigned its 'A' rating to the authority's $86.65 million series 2018A tax
exempt revenue bonds issued for the Dartmouth-Hitchcock Obligated group, along
with its $122.435 million series 2017A direct purchase loan with Citibank N.A.
and the $109.8 million 2017B and $10.97 million 2016B (formerly unrated)
direct purchase loans with T.D. Bank. We also assigned our 'A' rating to the
$302 million series 2018B taxable bonds issued by the Dartmouth-Hitchcock
Obligated Group.

In November 2016 we assigned a negative outlook on our ratings for D-HH's bond
because of its weak financial performance in fiscal 2016, driven by a
breakdown in the system's ability to accurately capture its revenue for that
fiscal year, and some uncertainty about its ability to recover operations and
generate operating margins in-line with our expectations for the rating level.
The stable outlook is due to management's swift corrective actions to
stabilize revenue and overall operations and leading improved financial
operating performance progressively through fiscal 2017 and through the first
four months of fiscal 2018 (period ended Oct. 31, 2017).

The 'A' rating reflects D-HH's robust enterprise profile serving as both the
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sole academic medical center and major safety net provider of care in New
Hampshire, along with its expansive community physician presence strategically
located across the state of New Hampshire and Southern Vermont. We think the
scale of D-HH's enterprise profile offsets some of its weaker financial
metrics compared with our expectations for the rating level. Through its
extensive performance improvement plan (PIP), D-HH has established financial
operating targets focused on profitability and healthier cash flow through
fiscal 2022 to support its strategic growth and capital spending goals. We
view these projections favorably and think they are plausible given
management's assumptions, although we recognize that D-HH hasn't posted
healthy operating margins, by our calculation, for several years.

The stable outlook reflects D-HH's improved financial performance through
fiscal 2017 and interim fiscal 2018, along with the expectation that it will
continue to achieve healthy operating and cash flow margins to support its
overall strategic plans. At this time, management has no imminent debt plans,
but instead will optimize the use of cash flow and proceeds from the series
2018B taxable debt issuance to fund its capital plans.

We could consider a negative outlook or a lower rating for D-HH if it reports
operating losses through the two-year outlook period. Any material degradation
of its balance sheet, either in the form of new debt or a significant use of
its unrestricted reserves, could also be given negative consideration.
We could consider a positive outlook toward the end of the outlook period if
D-HH maintains its enterprise profile, achieves its financial operating
targets and strengthens its balance sheet ratios to a level more in-line with
our expectations for an 'A+' rating; however, a higher rating requires a
longer trend of these results.

RELATED RESEARCH
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• U.S. Not-For-Profit Health Care Sector 2017 Outlook: Stable, Yet A Pen
Stroke Away From Unprecedented Change, Jan. 10, 2017
• U.S. Not-For-Profit Health Care System Median Financial Ratios -- 2016
vs. 2015, Aug. 24, 2017
• Health Care Providers And Insurers Pursue Value Initiatives Despite
Reform Uncertainties, May 9, 2013
• Standard & Poor's Assigns Industry Risk Assessments To 38 Nonfinancial
Corporate Industries, Nov. 20, 2013
• Alternative Financing: Disclosure Is Critical To Credit Analysis In
Public Finance, Feb. 18, 2014
• Health Care Organizations See Integration And Greater Transparency As
Prescriptions For Success, May 19, 2014
• U.S. Not-For-Profit Acute Health Care Ratios: Operating Performance
Weakens While Balance Sheets Are Stable, Aug. 24, 2017
• The U.S. Health Care Sector Outlook Is Stable, Though Industry Pressures

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Dartmouth-Hitchcock Obligated Group Bond Rating Outlook Revised To Stable From Neg On Improved Financial
Performance
Persist, Sept. 27, 2016
• Medicaid’s Status As An Open-Ended Entitlement Is On Life Support
Following The Election, Nov. 17, 2016
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Dartmouth-Hitchcock Obligated Group Bond Rating Outlook Revised To Stable From Neg On Improved Financial
Performance
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1/23/2018 [ Press Release ] Fitch Assigns 'A' Rating to Dartmouth-Hitchcock Obligated Group (NH) Revs; Outlook Positive
https://www.fitchratings.com/site/pr/1035441 1/6

Fitch Assigns 'A' Rating to Dartmouth-Hitchcock Obligated Group (NH) Revs; Outlook Positive

Fitch Ratings-New York-23 January 2018: Fitch Ratings has assigned a rating of 'A' to the following bonds issued on behalf of
Dartmouth-Hitchcock Obligated Group:

--$86.650 million New Hampshire Health and Education Facilities Authority revenue bonds, series 2018A;
--$301.995 million Dartmouth-Hitchcock Obligated Group taxable bonds, series 2018B;
--$122.435 million New Hampshire Education Facilities Authority revenue bonds, series 2017A;
--$109.800 million New Hampshire Education Facilities Authority revenue bonds, series 2017B;
--$10.970 million New Hampshire Education Facilities Authority revenue bonds, series 2016B;
--$14.530 million New Hampshire Health and Education Facilities Authority revenue bonds, series 2014B; and
--$26.735 million New Hampshire Health and Education Facilities Authority revenue bonds, series 2012 (Cheshire Medical Center).
Fitch has also assigned an Issuer Default Rating (IDR) of 'A' to Dartmouth-Hitchcock Obligated Group (OG).

The Rating Outlook is Positive.
The series 2018A and B (collectively series 2018) bond issuances were preceded by two bank debt transactions that closed in late
2017, the proceeds of which advance refunded the OG's series 2009 and 2010 bonds and refunded the series 2012A and 2012B
bonds on a current basis. The 2018 plan of finance will include approximately $87 million of tax exempt debt and $302 million of
taxable debt, which will be used to refinance all of OG's remaining debt outstanding, with the exception of its series 2012
(Cheshire), 2014A and 2014B issuances. Approximately $75 million of the taxable 2018 series will be new money financing, the
proceeds of which will be applied to future strategic capital spending plans.

SECURITY
Debt payments are secured by a pledge of the gross revenues of the OG. The OG accounted for approximately 95% of total
revenues and 93% of total assets of the consolidated entity (Dartmouth Hitchcock Health and Subsidiaries (D-HH)) as of fiscal year
2017 (June 30 year-end). Fitch's analysis is based on the consolidated entity.

ANALYTICAL CONCLUSION
The 'A' rating and Positive Outlook reflect Fitch's expectation that D-HH will continue to improve upon the results of its
Performance Improvement Plan and reduce its net adjusted debt to adjusted EBITDA to levels more consistent with a higher rating
even through normal cyclical volatility. The rating incorporates Fitch's expectation that D-HH will soon begin to generate EBITDA
margins of approximately 10%, factoring in management's plans for elevated capital spending over the next five years. Also,
midrange revenue defensibility, which is based on D-HH's position as the leading acute care provider in a broad, multi-state and
demographically stable market, which Fitch believes insulates it from significant competition.

KEY RATING DRIVERS
Revenue Defensibility: 'bbb' - Significant size and scale; market leader
D-HH's revenue defensibility through the cycle is midrange, indicating low Medicaid/self-pay as a percent of revenue, very strong
market share and reach and generally stable demographic trends in service area. Headquartered in Lebanon, NH, D-HH is the
largest provider of healthcare services in New Hampshire, the second largest in Vermont, and is the only academic medical center
in the state. As such, it has a very broad, multi-state draw for tertiary and quaternary services and a decided market share lead in
its primary service area (PSA). Demographic characteristics in the service area are generally favorable, as evidenced by low
Medicaid and self-pay as a percentage of gross revenues.

Operating Risk: 'a' - Continued improvement in margins expected
Fitch expects D-HH to continue to demonstrate strong cost management as it reaps the benefits of its expanding market footprint
and affiliations with regional providers and payors over the next several years. D-HH has averaged a 5.8% operating EBITDA
margin and a 6.8% EBITDA margin over the last five years, which includes a very weak fiscal 2016. However, through D-HH's
turnaround efforts, operating results experienced a marked improvement from fiscal 2016 to fiscal 2017 and Fitch expects
continued improvement over the next five fiscal years. Operating improvements included an increase in patient activity, not only in
terms of volume, but in case mix severity, combined with strategic workforce reductions and other structural cost containment
1/23/2018 [ Press Release ] Fitch Assigns 'A' Rating to Dartmouth-Hitchcock Obligated Group (NH) Revs; Outlook Positive
https://www.fitchratings.com/site/pr/1035441 2/6
initiatives, and an acceleration of a planned freeze on its defined benefit pension plan. Capital needs are expected to be
moderately elevated over the next several years as D-HH continues to make enhancements to its regional footprint to support its
already leading market share, as well as strategic renovations to maximize inpatient capacity at its headquarter facility.
Financial Profile: 'a' - Metrics consistent with higher rating through normal cyclical volatility
D-HH's financial and leverage profile is expected to continue to improve over time, as the organization improves its annual cash
flow, grows its unrestricted reserve position and gradually pays down its debt issuances. Despite Fitch's expectation of more
elevated capital expenditures over the next five years, D-HH retains a fair degree of flexibility in the timing of these expenditures
and is not planning additional debt issuance, which supports the expectation that leverage metrics will improve over the next five
years, even in a stress scenario.

Asymmetric Additional Risk Considerations
No asymmetric risk factors were applied in this rating determination. D-HH's proposed series 2018 financing will eliminate the
organization's exposure to variable rate debt and associated swaps, and reduce its put risk to immaterial levels, mitigating Fitch's
prior concerns about the risks associated with D-HH's current debt structure. Exposure to bullet maturity is not a credit concern,
given D-HH's adequate unrestricted cash resources to retire all of this debt. Similarly, Fitch does not consider recent management
changes, implemented during fiscal 2017, to be additive to D-HH's risk profile.

RATING SENSITIVITIES
SUSTAINED OPERATIONAL IMPROVEMENTS: The Positive Outlook reflects Fitch's expectation that management will continue
on its current trajectory and achieve its projections of an EBITDA margin of approximately 10%, net adjusted debt to adjusted
EBITDA approaching 0.0x and cash to adjusted debt approaching 120%, which would likely result in a higher rating over the next
two years. Positive rating action could be constrained if operations falter or fail to track management's articulated levels. This
would result in unrestricted liquidity declines below current and projected levels, pressuring the key leverage metrics that currently
support the rating outlook.

CREDIT PROFILE
D-HH provides high acuity care to an extensive geographic region through its flagship academic medical center, Mary Hitchcock
Memorial Hospital (MHMH) and its physician clinic, Dartmouth Hitchcock Clinic (the Clinic). The OG includes MHMH, the Clinic,
Cheshire Medical Center (Keene, NH), Mt. Ascutney Hospital (Windsor, VT), and New London Hospital (New London, NH). Alice
Peck Day Memorial Hospital (Lebanon, NH) is expected to join the OG shortly.

Revenue Defensibility
Consistent with demographic trends in its service area, D-HH's payor mix is balanced towards Medicare and commercial paying
patients, with a gross revenue mix of 43% Medicare, 38% commercial, 13% Medicaid, and 4% self-pay/other in fiscal 2017.
Medicaid and self-pay combined were well under 25% in fiscal 2017.
New Hampshire does assess its healthcare providers with a Medicaid Enhancement Tax (MET), with revenues intended to support
Medicaid services in the state. The program has stabilized following a settlement with the state in June 2014 and is not a rating
concern at this time. In fiscal 2017, D-HH received supplemental payments from the program that exceeded the MET paid by a
little over $1.1 million.

Headquartered in Lebanon, NH, D-HH is the largest provider of health care services in New Hampshire and the second largest
provider of health care services in Vermont. As New Hampshire's only academic medical center, D-HH maintains a strong, leading
market share, relative to those of its nearest competitors, which are primarily small community hospitals that do not offer the array
of tertiary and quaternary services that are available at D-HH. Its Medicare Case Mix Index is among the highest in the nation at
2.18 as of Dec. 31, 2017. The nearest hospitals that offer a comparable array of services are located in Burlington, VT and Boston,
MA, both of which are about 100 miles away. D-HH's market share trends have been increasing annually, mostly through
increased affiliations with regional providers and more expansive use of telemedicine, strategies that have alleviated capacity
constraints at D-HH's main facility.

D-HH has a decided market share lead in its primary service area (PSA), which spans an extensive geographic area consisting of
a six-county region across New Hampshire and Vermont. Based on calendar year 2015 data (the most recently available), D-HH
captured over 82.5% market share in its PSA. However, the majority of D-HH's patients (57.1%) travel to the hospital from areas
throughout its secondary service area (SSA), which it defines as the entire states of New Hampshire and Vermont. In 2015, D-HH
captured systemwide market share of 21.6% and 26.8% in New Hampshire and Vermont, respectively. No other hospital in New
Hampshire captured more than 11.4% market share within the state and no other in-state competitor captured market share from
Vermont. For the population consisting of all New Hampshire not-for-profit hospitals (24 out of 26 hospitals), D-HH hospitals
accounted for 36% of total inpatient surgeries, 24% of inpatient admissions, and 31% of revenue for the 12 months ended Dec. 31,
1/23/2018 [ Press Release ] Fitch Assigns 'A' Rating to Dartmouth-Hitchcock Obligated Group (NH) Revs; Outlook Positive
https://www.fitchratings.com/site/pr/1035441 3/6
2016.
D-HH's market position is further enhanced by its designation as the only NCI comprehensive cancer center (one of 49 in the
U.S.), Level I trauma, full service children's hospital, Level III NICU and air transport operator in the state. It consistently receives
awards and recognition for its quality and safety outcomes.

D-HH's service area characteristics are generally stable, particularly in Lebanon/Grafton County, NH. Based on U.S. Census
Bureau and U.S. Bureau of Labor Statistics data, Grafton County and the states of New Hampshire (IDR AA+/Stable) and Vermont
(AAA/Stable) are all characterized by above average median household income level, below average poverty rate, low
unemployment rate and relatively flat population growth, supporting an overall 'midrange' assessment of D-HH's service area
characteristics.

Operating Risk
Following very weak operating performance in fiscal 2016, management implemented a Performance Improvement Plan (PIP) for
MHMH and the Clinic, consisting of $120 million worth of both expense cuts and revenue enhancements, which stabilized its
operations in fiscal 2017. Results of the PIP exceeded the objectives laid out to Fitch at our last review.

Longer range financial projections show D-HH gradually improving both operating and cash flow margins over the next several
years, with a projected EBITDA margin of about 10% in fiscal 2022. Fitch believes these projections are reasonable, given the
structural nature of the cost containment measures implemented as part of the PIP, which decreased cost per unit by 11.6% since
the third quarter of fiscal 2016, and that position the organization to sustain operational improvements over the longer term. In
addition, Fitch expects D-HH to continue to see consistent revenue growth from additional volumes, in particular higher acuity
volumes, as well as a significant improvement in days in accounts receivable to 48 days at the end of fiscal 2017 from 58 days as
of fiscal 2016.

D-HH's capital spend rate has historically been adequate to deliver quality clinical outcomes, with expenditures that have averaged
over 97% of depreciation over the past five fiscal years. Still, lifecycle investment needs are moderately elevated, with an average
age of plant of 13.0 years at fiscal year-end 2017, compared to the all ratings median of 11.0 years.

Fitch expects D-HH's future capital investment to be elevated relative to its historical spend rate. Its five-year capital budget totals
approximately $660 million, of which $75 million is expected to be funded from series 2018 proceeds. This represents an average
spend of about $131 million per year, compared to $77 million in fiscal 2017, and D-HH's estimated $70 million of routine
expenditures in each year of its capital plan. Main areas of strategic capital investment include expansion of D-HH's EPIC system
to affiliate locations, development of regional facilities in the southern region of New Hampshire, renovations to D-HH's Lebanon,
NH facility to increase inpatient bed capacity at headquarters, and modernization and expansions to existing surgical facilities, all
of which are consistent with D-HH's overall organizational strategy. D-HH expects to fund the majority of its capital plan through a
combination of cash flow from operations, investment earnings, lease financing and fundraising. No additional debt is planned
beyond the series 2018 transaction.

D-HH's operating risk assessment is enhanced by its vertically integrated delivery model that focuses the organization on
population health management and shifting payments models to be value based versus volume based. D-HH has employed
physicians for over 90 years, with 1,437 physicians employed across D-HH's hospitals in 2017. In addition, collaborations are in
place with other providers and payors to create a wider network that can leverage support services to execute on management's
strategy of managing lives across NH and VT. D-HH participated in cost and quality-based risk contracts for over 200,000 covered
lives in fiscal 2017.

Financial Profile
Despite some liquidity erosion as a result of operating losses in fiscal 2016, D-HH's financial profile is consistent with an 'a'
assessment, with further improvements expected over the next five years. Cash to adjusted debt was 90% at the end of fiscal 2017
and net adjusted debt to adjusted EBITDA was very low at 0.5x as of fiscal 2017. Leverage metrics have shown improvement
through the four months ended Oct. 31, 2017.

D-HH demonstrates growth consistent with its recent year-over-year trend, during the base case scenario, which results in
improving cash flow and gradual liquidity accretion, which supports the existing 'A' rating. Cash to adjusted debt begins at 97% as
of fiscal 2018 year end and gradually improves to over 150% during the base case scenario. Net adjusted debt to adjusted
EBITDA begins at 0.1x and improves to -1.3x, again showing solid cash accretion over the base case, predicated on
management's ability to sustain operational improvements over a five year timeframe and incorporating D-HH's plans for elevated
capital spending over the next five years.

The rating case applies Fitch's standard stress to D-HH over the five year time period and the credit nevertheless shows
improvement through the five year cycle. As one might expect, cash to adjusted debt declines incrementally as it is subjected to a
1/23/2018 [ Press Release ] Fitch Assigns 'A' Rating to Dartmouth-Hitchcock Obligated Group (NH) Revs; Outlook Positive
https://www.fitchratings.com/site/pr/1035441 4/6
period of economic and operational stress and falls to a low of 87% in fiscal 2018, but rebounds to current levels within three
years, and then resumes its growth pattern consistent with the base case, ultimately reaching 114% in year five. The rating case
scenario incorporates an assumption that D-HH scales back on its capital expenditures during the period of stress, but then
resumes its planned average spend in years three through five.

D-HH's asset allocation exhibits a moderate degree of sensitivity during an economic downturn. However, its net adjusted debt to
adjusted EBITDA remains below 1.0x for the duration of the rating case, ranging from a high of 0.8x in year 1 to a low of -0.4x in
the final year of the rating case, which are metrics more consistent with a rating in the higher end of the 'A' category.
D-HH implemented a freeze of its defined benefit pension plan in January 2017. The plan was 78% funded at the end of fiscal
2017, with no additional liabilities to be accrued following the freeze.

Asymmetric Additional Risk Considerations
No asymmetric risk considerations were identified.
Fitch does not consider D-HH's debt structure to be additive to its risk profile. The series 2018 financing was preceded by two bank
debt transactions completed at the end of calendar year 2017 that refunded D-HH's series 2009, 2010, and 2012A &B bonds.
These transactions and the planned series 2018 financing collectively represent a wholesale recapitalization of D-HH's balance
sheet, with approximately $75 million of series 2018 bond proceeds expected to be applied to new money capital projects, and the
balance expected to be used to refinance all but about $69 million of D-HH's approximately $630 million of outstanding debt.
Following the series 2018 issuance, 100% of D-HH's debt will be fixed rate and it will have no exposure to variable rate debt or
associated swaps, and substantially all of its put risk will be eliminated. Following the 2018 issuance, D-HH will have exposure to a
$312 million bullet maturity in fiscal 2048; however, D-HH maintains sufficient cash to retire all of this debt, with unrestricted cash
and investments of $695 million as of Oct. 31, 2017 covering the bullet maturity by over 2.2x.

D-HH made adjustments to its senior management team, including moving its COO into the role of CFO, during fiscal 2017. During
this same time period, the former CEO, Dr. James Weinstein, announced his retirement. Following a national search, the board
named Dr. Joanne Conroy as CEO in June 2017. Dr. Conroy comes to D-HH from a position as CEO of Lahey Hospital and
Medical Center in Burlington, MA. Fitch does not consider these changes to be additive to D-HH's risk profile.

Contact:
Primary Analyst
Margaret Johnson
Director
+1-212-908-0545
Fitch Ratings, Inc.
33 Whitehall Street
New York, NY 10004
Secondary Analyst
Gary Sokolow
Director
+1-212-908-9186
Committee Chairperson
Kevin Holloran
Senior Director
+1-512-813-5700
Media Relations: Hannah James, New York, Tel: + 1 646 582 4947, Email: hannah.james@fitchratings.com.
Additional information is available on www.fitchratings.com
In addition to the sources of information identified in the applicable criteria specified below, this action was informed by information
from Lumesis.

Applicable Criteria
Rating Criteria for Public Sector Revenue-Supported Debt (pub. 05 Jun 2017) (https://www.fitchratings.com/site/re/898969)
U.S. Not-For-Profit Hospitals and Health Systems Rating Criteria (pub. 09 Jan 2018) (https://www.fitchratings.com/site/re/913974)
1/23/2018 [ Press Release ] Fitch Assigns 'A' Rating to Dartmouth-Hitchcock Obligated Group (NH) Revs; Outlook Positive
https://www.fitchratings.com/site/pr/1035441 5/6

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1/23/2018 [ Press Release ] Fitch Assigns 'A' Rating to Dartmouth-Hitchcock Obligated Group (NH) Revs; Outlook Positive
https://www.fitchratings.com/site/pr/1035441 6/6
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