The pillaging of Steward Health Care: Appendix B

November 2010 – Cerberus Capital Management, through a newly formed company called Steward Health Care, acquires six Massachusetts hospitals from nonprofit Caritas Christi Health Care in a leveraged buyout. The overall deal is valued at $895 million.[1] Of the $895 million price tag, $475 million is assumed debt and pension liabilities[2] and a reported leveraged buyout cost of $420 million. Cerberus only puts up $246 million in cash,[3] approximately 27 percent of the deal value. Massachusetts regulators approve the deal, but impose multiple conditions including a five-year monitoring period.[4]

May 2011 – Steward acquires Nashoba Valley Medical Center and Merrimack Valley Hospital from Essent Healthcare.[5]

September 2011 – Steward acquires Quincy Medical Center and Morton Hospital in Massachusetts.[6]

April 2012– Steward sells 13 medical office buildings to Healthcare Trust of America, an Arizona-based real estate investment trust (REIT) for $100 million.[7]

September 2012 – Steward acquires New England Sinai Hospital in Stoughton, Massachusetts.[8]

July 2013 – Morton Hospital in Taunton, Massachusetts, closes its pediatric ward.[9]

March 2014 – Steward announces it will merge Merrimack Valley Hospital with Holy Family Hospital in Haverhill, Massachusetts.[10]

November 2014 – Steward announces it plans to close Quincy Medical Center, three years after acquiring it.[11] Steward made an agreement with the Massachusetts Attorney General when it acquired the hospital to keep the hospital open for at least six and a half years and give 18 months’ notice before shutting it down.[12] Typical regulations require 90 days’ notice and a public hearing before a hospital closure. The closure results in the displacement of 700 jobs.[13]

December 2014

• Steward fails to provide consolidated financial statements to Massachusetts regulators, racking up $1,000 per week in fines.[14]
• Steward closes all services but the Emergency Department at Quincy Medical Center. It had attempted to close the whole hospital, but regulators required it to keep emergency services open.[15]
• Steward sells the real estate of New England Sinai Hospital in a $23.5 million sale-leaseback transaction with Sila Realty Trust.[16]

January 2016 — Steward sells two vacant properties in Massachusetts for $21 million, reportedly to pay down some debt.[17]

September 16, 2016 – Steward and MPT execute a $1.2 billion real estate acquisition deal for nine of its Massachusetts hospitals. MPT makes an additional $50 million equity investment in Steward and commits to providing $1 billion in future Steward hospital acquisitions.[18] At least $484 million of the deal is used to pay dividends to investors.[19]

• Four of the hospitals are mortgaged by MPT: Carney Hospital, Holy Family (Haverhill). Norwood Hospital, and Nashoba Valley Medical Center. The remaining five undergo sale-leaseback deals: Good Samaritan, Sant Anne’s, Holy Family (Methuen), Morton Hospital, and St. Elizabeth’s.[20]

October 2016 – MPT issues 10.3 million shares of common stock to Cerberus Capital Management and members of Steward management, generating proceeds of $150 million.[21]

November 2016 – Steward acquires Central Massachusetts Independent Physician Association in a leveraged buyout for an undisclosed amount.[22]

December 2016 – Steward sells Quincy Medical Center’s real estate in Massachusetts to FoxRock Properties. According to the Patriot Ledger, FoxRock acquired the property for less than half what Steward paid for it through Bankruptcy Court in 2011; the property was valued for “tax purposes at $42.1 million – about three-and-a-half times the amount FoxRock paid for it.”[23]

May 2017 – In a $304 million transaction in which 99 percent is paid by MPT, Steward acquires eight hospitals from Community Health Systems, marking the beginning of its expansion outside of Massachusetts. The hospitals are located in Florida, Ohio, and Pennsylvania.[24] MPT effectively finances the transaction by acquiring the real estate of all the hospitals for $301.3 million to lease back to Steward.[25]

September 2017

• In a deal first announced in May 2017,[26] Steward acquires 18 hospitals from IASIS Healthcare, a health system owned by private equity firm TPG.[27] This transaction expands Steward’s footprint to Arizona, Arkansas, Colorado, Louisiana, Texas, and Utah, and transforms it into the largest for-profit private hospital chain in the US.[28] As part of the transaction, MPT purchases the real estate of the Arkansas facility, three of the Arizona facilities, three Texas facilities, and four of the five Utah properties from IASIS in a $1.4 billion transaction. This transaction is comprised of a $700 million sale-leaseback and $700 million mortgage, of which Steward will assume lease and mortgage payments.[29] An additional four of the hospitals purchased from IASIS already underwent sale-leasebacks with MPT under the ownership of IASIS,[30] and MPT will continue to own and lease that real estate to Steward.
• MPT also makes a $100 million equity investment in Steward.[31]

November 2017 – Steward sues Massachusetts state officials to avoid financial disclosures after it has racked up at least $300,000 in fines for violating state regulations. Becker’s Hospital Review reports “Steward filed heavily redacted annual financial reports for 2014 and 2015 with [Center for Health Information and Analysis] and reported no information for 2016. According to The Boston Globe, Steward is the only organization that has repeatedly failed to submit the financial information to CHIA.” [32]

February 2018 – Steward announces a public-private partnership with the country of Malta to operate various government owned facilities, as well as open a satellite medical and dental school, launching Steward International.[33]

March 2018

• Steward’s Morton Hospital in Taunton, Massachusetts cuts maternity services, which will mean pregnant patients will need to travel 20 miles to have their babies at Steward’s Good Samaritan Hospital in Brockton. According to the Boston Globe, the cuts “could pose a hardship in a city where poverty is higher and incomes are lower than they are statewide, and patients may lack easy access to transportation.”[34]
• MPT sells the real estate of Steward’s St. Joseph Hospital in Houston back to Steward for $148 million in exchange for a mortgage loan of the same amount.[35]

August 2018 – Steward moves its headquarters from Boston, MA to Dallas, TX.[36]

September 2018 – Steward closes Northside Regional Medical Center in Youngstown, Ohio, resulting in the layoffs of at least 468 workers[37] and the loss of the city’s only labor and delivery unit.[38]

February 2019 – Steward announces the creation of a new business line called Titan Risk Retention Group, which will “offer professional liability coverage to physicians and health care professionals practicing in 48 of the 50 states, protecting them from volatile prices and reducing costs” according to the company’s press release.[39]

April 2019 – Steward acquires Scenic Mountain Medical Center in Big Spring, Texas.[40] MPT acquires the real estate concurrently.[41]

September 2019 – Steward opens Florence Hospital in Arizona.[42] MPT already owns the real estate of this hospital,[43] which went bankrupt in 2018 when its operations were owned by New Vision Health.[44]

November 2019 – Steward closes St. Luke’s Medical Center in Phoenix, Arizona, resulting in the layoffs of 655 workers.[45]

March 2020 – Steward writes a letter to Pennsylvania’s Governor requesting a $40 million bailout to prevent the closure of its Easton Hospital. With the pandemic underway, the state was preparing for a surge in patients. Easton mayor Sal Panto told WSJ, “That’s how they kept the state hostage.” The state ultimately agreed to provide the hospital with $8 million.[46]

May 2020

• Cerberus begins its exit from Steward Health Care, with the help of MPT. First, Cerberus issues a promissory note due in five years to a group of Steward physician executives, including de la Torre, for its 90 percent ownership stake.[47]
• The Arizona Division of Insurance approves Steward CEO Ralph De La Torre’s and his holding company’s acquisition of Titan Risk Retention Group and Steward Health Choice, Inc., two of Steward’s business lines.[48]

July 2020 – Steward sells Easton Hospital in Pennsylvania to St. Luke’s University Health Network for $15 million.[49] MPT receives $62 million for the property.[50]

Summer 2020 – MPT provides a $400 million cash infusion into Steward at Cerberus’ behest. First, MPT forms a new joint venture with de la Torre and other Steward executives to buy Steward International using a $205 million loan from MPT, despite the fact that the international business is only valued at $27 million.[51] Then, MPT forgives a $750 million mortgage on two of the Utah hospitals and pays $200 million to Steward for the hospitals.[52]

September 2020 – Bloomberg reports that Steward Health Care has received $675 million in federal pandemic-related loans and grants.[53]

November 2020 – Quincy Medical Center in Massachusetts permanently closes its emergency department, leaving the city of Quincy with no emergency room.[54]

January 2021

• MPT provides a $335 million loan to affiliates of Steward,[55] used by Steward executives to buy Cerberus’ note at a $15 million discount. Cerberus fully exits its Steward investment.[56]
• Steward pays a $111 million dividend to its new physician owners.[57]

March 2021 – Steward announces plans to build a new hospital in St. George, Utah that will reportedly open by October 2023.[58] (As of this writing, the hospital has not opened).[59]

May 2021 – Steward announces $92 million in planned renovations at St. Joseph Medical Center in Houston, Texas.[60]

August 2021 – Steward buys five more hospitals in south Florida. Keeping with its usual practice, MPT acquires the real estate concurrently to then sell back to Steward. The price tag for the transaction is $900 million, and it appears it went to the real estate alone.[61]

March 2022 – MPT executes a $1.7 billion recapitalization transaction for eight of Steward’s Massachusetts’s hospitals in which one of Macquarie Asset Management’s funds establishes a 50 percent stake in the real estate of eight of Steward’s Massachusetts general acute care hospitals.[62] Apollo Global Management and its affiliates provide a $920 million loan for the transaction,[63] which is secured by the hospitals.[64] MPT reports $1.3 billion in cash proceeds from the transaction.[65]

April 2022 – Steward acquires Abrazo Mesa Hospital in Arizona and renames it Steward Mesa Hospital.[66] It also acquires a closed hospital facility in Miami, Florida, although it never opens it. MPT pays $80 million for the two properties,[67] $60 million of which goes to the Florida hospital.[68]

June 10, 2022 – Steward agrees to pay $4.7 million to resolve allegations of False Claims Act violations related to one of its Massachusetts hospitals.[69]

November 2022 – Steward sells its value-based care business, an “integrated physician network and managed care contracting business” that includes 1,800 primary care physicians, to CareMax, Inc. for $25 million.[70] CareMax also issues 23.5 million shares of Class A Common Stock, valued at $138.5 million, as part of the transaction.[71] As part of the deal, Steward Health Care and CareMax enter “into an exclusive access agreement pursuant to which [Steward Health Care Network] is required to exclusively make its participating provider network available to CareMax for the provision of services to MA members under MA risk agreements for an initial period of ten years..”[72]

February 2023 – CommonSpirit Health enters a definitive agreement with Steward Health Care to purchase Steward’s Utah hospital operations (five hospitals in total) and lease the real estate from MPT. [73]

April 2023 – Steward closes Texas Vista Medical Center in San Antonio, Texas. According to CBS, the closure “will leave a population of about half a million people with just one full-service hospital which has 110 beds. The average nationwide ratio is 2.38 beds per 1,000 people. Texas Vista’s closure will bring this area’s ratio to 0.2 per 1,000.”[74] The hospital was at least $650,000 behind in payments to various vendors and was attempting to get out of its lease obligations with MPT prior to the closure.[75] 827 workers were laid off.[76]

Summer 2023 – Steward refinances a portion of its debt with a $600 million loan from a consortium of private credit lenders.[77]

August 17, 2023 – Medical Properties Trust sells $105 million of its interest in Steward’s syndicated asset-backed credit facility.[78] 

September 2023 – Federal and state officials in Massachusetts cite Good Samaritan Hospital in Brockton, MA for putting patients in immediate jeopardy. MNA had been warning officials since 2021 about critical understaffing and major safety issues in the emergency department.[79]

October 2023 – A woman who gave birth at Steward’s St. Elizabeth’s Medical Center in Massachusetts dies after the embolization coil needed to stop a bleed following childbirth was unavailable. It had been repossessed by the company that owned it because Steward had not paid its bill.[80]

December 2023

• Steward notifies Massachusetts healthcare officials its plans to close New England Sinai Acute Long-Term Care and Rehabilitation Hospital, a 182 bed-hospital.[81]
• The federal government files a second False Claims Act suit against Steward.[82]

January 2024

• MPT announces that as of December 31, 2023, Steward Health Care was $50 million behind in rent payments.[83]
• Steward sells its lab assets in Ohio and Pennsylvania to Quest Diagnostics for an undisclosed amount. [84]

February 2024

• Steward’s North Shore Medical Center in Florida ends obstetrics services, including neonatal unit and labor and delivery.^[85]
• Massachusetts Governor Healey shares that Steward has not provided the state with audited financial records. NBC Boston quotes the governor as saying “that the hospital system did not produce records signed by an auditor because she suspects no auditor was willing to sign off on them.”[86]
• The Boston Globe reports that the temporary closure of Norwood Hospital may become permanent because construction of the replacement facility has stopped. Steward reportedly is not paying its bills and there are multiple liens on the property.[87]
• Steward closes the Medical Center of Southeast Texas’s Beaumont campus on Feb 2.[88]
• Steward receives a $150 million loan from a consortium of lenders to help stabilize its finances.[89]
• Massachusetts Senators Ed Markey and Elizabeth Warren sent a letter to Cerberus Capital Management requesting information about how it had contributed to Steward’s financial situation. Cerberus responded the same month. 

March 2024

• Steward closes Glenwood Rehabilitation Center, located within Glenwood Regional Medical Center in West Monroe, Louisiana, amidst deteriorating finances and patient care issues.[90]
• Massachusetts Senator Ed Markey publicly invites Steward CEO, Ralph De La Torre, to testify at the health, education, labor and pensions committee’s field hearing in Boston on April 2.[91]
• Steward announces an agreement to sell its physician network, Stewardship Health, to UnitedHealth Group’s Optum Care.[92]
• Southcoast Health expresses a desire to purchase one of Steward’s ailing MA hospitals, St. Anne’s Hospital in Fall River.[93]
• WSJ reports that MPT may be involved in a Securities and Exchange Commission (SEC) investigation.[94]
• The Boston Globe reports that Steward’s hospitals are “paid the same as or better than many Massachusetts hospital systems for the medical care they provide,” despite the fact that “Steward Health Care executives have repeatedly blamed the financial disaster unfolding at their Massachusetts hospitals on stingy payments from health insurers.”[95]

April 2024

• Steward closes New England Sinai Hospital in Stoughton, Massachusetts.[96]
• The Senate Health, Educations, Labor, and Pensions (HELP) Subcommittee on Primary Health and Retirement Security holds a field hearing on Boston on corporate greed in healthcare, in which witnesses provide scathing critiques of Steward Healthcare and Cerberus Capital Management.[97]
• In a $1.1 billion transaction, MPT sells its majority interest in the real estate of Steward’s former Utah hospitals to a newly formed joint venture with an undisclosed investor. MPT retains a 25 percent stake in the properties.[98]
• Louisiana state lawmakers hold a hearing over the financial and patient care crisis at Glenwood Regional Medical Center in West Monroe, Louisiana.[99] Various clinicians testify about the state of the hospital, describing how financial distress has resulted in patient harm.[100]
• Massachusetts Senators Ed Markey and Elizabeth Warren call on Medical Properties Trust and Macquarie Infrastructure Partners “to reduce lease payments or terminate their leases to enable new owners to buy the financially squeezed hospitals.”[101] They also sent letters to Steward’s creditors asking them to modify Steward’s loan terms to help keep the hospitals running.^[102]

May 2024

• Steward Health Care files for Chapter 11 bankruptcy in the Southern District of Texas bankruptcy court, Houston Division,[103] reporting more than $9 billion in liabilities. Long term lease liabilities account for the largest portion of debt ($6.6 billion). It owes nearly $1 billion to vendors and medical suppliers, has $1.2 billion in loan debts, and owes nearly $290 million in unpaid compensation to employees and staffing firms.[104] Steward’s bankruptcy is one of the largest hospital bankruptcies in decades.[105]
• The Arizona Attorney General, Kris Mayes, announces an investigation into Steward Health Care.[106]

[1]FierceHealthcare. “Acquisition of Caritas Christi Now Complete.” November 9, 2010. https://www.fiercehealthcare.com/healthcare/acquisition-caritas-christi-now-complete.

[2] Pg. 38 of Batt, Rosemary, Eileen Appelbaum, and Tamar Katz. “The Role of Public REITs in Financialization and Industry Restructuring – Working Paper No. 189.” Center for Economic and Policy Research, July 9, 2022. https://www.ineteconomics.org/uploads/papers/WP_189-Batt-Appelbaum-Public-REITS-2.pdf.

[3] Sabrina Willmer. “Cerberus Quadruples Money After Unusual Exit From Hospital Giant.” Bloomberg.Com, May 27, 2021. https://www.bloomberg.com/news/articles/2021-05-27/cerberus-quadruples-money-after-unusual-exit-from-hospital-giant.

[4] Pgs. 20-21 of La France, Aimee, Rosemary Batt, and Eileen Appelbaum. “Hospital Ownership and Financial Stability: A Matched Case Comparison of a Non-Profit and Private Equity Owned Health System.” Center for Economic and Policy Research, March 22, 2021. https://cepr.net/wp-content/uploads/2022/03/LBA-Advances-Chapter-Final-03-24-21.pdf.

[5]Nashoba Valley Voice. “Nashoba Valley Medical Center Bought by Steward Health Care.” December 17, 2010. https://www.nashobavalleyvoice.com/ci_16883492/; FierceHealthcare. “Essent Healthcare Finalizes Sale of Two Massachusetts Hospitals,” May 4, 2011. https://www.fiercehealthcare.com/healthcare/essent-healthcare-finalizes-sale-two-massachusetts-hospitals.

[6] Weisman, Robert. “Steward Finalizes Purchases of Morton, Quincy Medical Center Hospitals.” Boston.Com, September 30, 2011. https://www.boston.com/uncategorized/noprimarytagmatch/2011/09/30/steward-finalizes-purchases-of-morton-quincy-medical-center-hospitals/.

[7]Becker’s Hospital Review. “Steward Sells 13 Medical Offices Worth $100M to Healthcare Trust of America.” April 18, 2012. https://www.beckershospitalreview.com/hospital-transactions-and-valuation/steward-sells-13-medical-offices-worth-100m-to-healthcare-trust-of-america.

[8]Becker’s Hospital Review. “Steward Health Care System Finalizes Acquisition of New England Sinai Hospital.” September 4, 2012. https://www.beckershospitalreview.com/hospital-transactions-and-valuation/steward-health-care-system-finalizes-acquisition-of-new-england-sinai-hospital.

[9] Conaboy, Chelsea. “Unit at Morton Hospital Essential, State Says.” The Boston Globe, June 11, 2013. https://www.bostonglobe.com/lifestyle/health-wellness/2013/06/10/state-morton-hospital-pediatric-unit-slated-closed-provides-critical-care-mass-presses-morton-hospital-reconsider-closing-pediatric-unit/JSZkSKBav8DhrE5I3EefLO/story.html.

[10] holyfamilyhospital.org. “Merrimack Valley Hospital and Holy Family Hospital to Merge: Holy Family Hospital in Methuen & Haverhill MA | Steward Hospitals,” March 14, 2014. https://www.holyfamilyhospital.org/article/merrimack-valley-hospital-and-holy-family-hospital-to-merge.

[11] Ronan, Patrick. “Quincy Hospital Property Sold in Major Deal with Downtown Implications.” The Patriot Ledger, December 8, 2016. https://www.patriotledger.com/story/news/politics/county/2016/12/08/quincy-hospital-property-sold-in/24293800007/.

[12] McCluskey, Priyanka Dayal, and Robert Weisman. “Quincy Medical Center to Close.” The Boston Globe, November 6, 2014. https://www.bostonglobe.com/business/2014/11/06/steward-shut-down-quincy-medical-center-largest-massachusetts-hospital-closure-decade/bVl0qPstKwouQLMKQ3UJiI/story.html.

[13] McCluskey, Priyanka Dayal, and Robert Weisman. “Quincy Medical Center to Close.” The Boston Globe, November 6, 2014. https://www.bostonglobe.com/business/2014/11/06/steward-shut-down-quincy-medical-center-largest-massachusetts-hospital-closure-decade/bVl0qPstKwouQLMKQ3UJiI/story.html.

[14] Torrieri, Marisa. “MA State Imposes $1,000-per-Week Penalty on Steward Health Care System.” Healthcare Dive, December 19, 2014. https://www.healthcaredive.com/news/ma-state-imposes-1000-per-week-penalty-on-steward-health-care-system/345671/.

[15] DiFazio, Joe. “Quincy Medical Center Closes for Good.” The Patriot Ledger, November 1, 2020. https://www.patriotledger.com/story/news/2020/11/01/quincy-medical-center-closes-for-good/114602450/.

[16] Sila Realty Trust. “Properties Archive.” Accessed May 24, 2024. https://silarealtytrust.com/portfolio/; Pg. 36 of “Reports on Steward Health Care System Pursuant to 2010 and 2011 Assessment & Monitoring Agreements.” Commonwealth of Massachusetts, December 30, 2015. https://wayback.archive-it.org/1101/20180104140223/http:/www.mass.gov/ago/docs/healthcare/shcs-report-123015.pdf.

[17]Becker’s Hospital Review. “Steward Health Care Sells 2 Vacant Properties.” January 15, 2016. https://www.beckershospitalreview.com/finance/steward-health-care-sells-2-vacant-properties.html.

[18] Steward Health Care System. “Steward Receives $1.25 Billion Investment from Medical Properties Trust, Setting Stage for National Growth.” Accessed March 14, 2024. https://www.prnewswire.com/news-releases/steward-receives-125-billion-investment-from-medical-properties-trust-setting-stage-for-national-growth-300334227.html.

[19] Hechinger, John, and Sabrina Willmer. “Life and Debt at a Private Equity Hospital.” Bloomberg, August 6, 2020. https://www.bloomberg.com/news/features/2020-08-06/cerberus-backed-hospitals-face-life-and-debt-as-virus-rages.

[20] Pg. 376; Pgs. 595-596; “(2016) Form 10-K Medical Properties Trust, Inc. MPT Operating Partnership, L.P.” Medical Properties Trust, March 1, 2017. https://medicalpropertiestrust.gcs-web.com/static-files/ab777b9c-b38e-45dc-b39a-a2cd30fab2cb.

[21] Pg. 58 of “(2016) Form 10-K Medical Properties Trust, Inc. MPT Operating Partnership, L.P.” Medical Properties Trust, March 1, 2017. https://medicalpropertiestrust.gcs-web.com/static-files/ab777b9c-b38e-45dc-b39a-a2cd30fab2cb.

[22] “PitchBook Profile – Central Massachusetts Independent Physician Association.” Accessed May 20, 2024. https://my.pitchbook.com/profile/167279-32/company/deals#deal-80483-68T; Worcester Business Journal. “Steward Extending Reach into Central Mass.” November 10, 2016. https://www.wbjournal.com/article/steward-extending-reach-into-central-mass.

[23] Ronan, Patrick. “Quincy Hospital Property Sold in Major Deal with Downtown Implications.” The Patriot Ledger, December 8, 2016. https://www.patriotledger.com/story/news/politics/county/2016/12/08/quincy-hospital-property-sold-in/24293800007/.

[24] McCluskey, Priyanka Dayal. “Steward Buys Eight Hospitals for $304 Million – The Boston Globe.” The Boston Globe, May 9, 2017. https://www.bostonglobe.com/business/talking-points/2017/05/09/steward-buys-eight-hospitals-for-million/fBUn3CgjIB4xGXfsxnYM8M/story.html.

[25] “EX-99.1.” Accessed May 20, 2024. https://www.sec.gov/Archives/edgar/data/1287865/000119312517370864/d475008dex991.htm.

[26] Cerberus Capital Management. “Steward Health Care And IASIS Healthcare Announce Definitive Agreement To Merge,” May 19, 2017. https://www.cerberus.com/media-center/steward-health-care-and-iasis-healthcare-announce-definitive-agreement-to-merge/.

[27] Bryant, Meg. “Steward Becomes Largest Private For-Profit Hospital System with IASIS Purchase.” Healthcare Dive, October 3, 2017. https://www.healthcaredive.com/news/steward-becomes-largest-private-for-profit-hospital-system-with-iasis-purch/506324/; Carey, David. “TPG Sells Iasis to Steward Health Care for $2 Billion.” Bloomberg.Com, May 19, 2017. https://www.bloomberg.com/news/articles/2017-05-19/tpg-said-to-sell-iasis-to-steward-health-care-for-2-billion.

[28] Bryant, Meg. “Steward Becomes Largest Private For-Profit Hospital System with IASIS Purchase.” Healthcare Dive, October 3, 2017. https://www.healthcaredive.com/news/steward-becomes-largest-private-for-profit-hospital-system-with-iasis-purch/506324/.

[29] Bubny, Paul. “MPT Closes on $1.4B Hospital Deal.” GlobeSt, October 2, 2017. https://www.globest.com/sites/paulbubny/2017/10/02/mpt-closes-on-1-4b-hospital-deal/; “EX-99.1.” Accessed May 20, 2024. https://www.sec.gov/Archives/edgar/data/1287865/000119312517370864/d475008dex991.htm.

[30] Medical Properties Trust. “Medical Properties Trust, Inc. (NYSE: MPW) – Medical Properties Trust, Inc. Announces Completion of Acquisition of Three IASIS Facilities,” September 30, 2013. https://medicalpropertiestrust.gcs-web.com/node/6581/pdf; Pg. 112 of “(2018) Form 10-K Medical Properties Trust, Inc. MPT Operating Partnership, L.P.” Medical Properties Trust, March 1, 2019. https://medicalpropertiestrust.gcs-web.com/static-files/deb797d1-f880-43df-b808-451e3a1eab18.

[31] Pg. 46 of “(2018) Form 10-K Medical Properties Trust, Inc. MPT Operating Partnership, L.P.” Medical Properties Trust, March 1, 2019. https://medicalpropertiestrust.gcs-web.com/static-files/deb797d1-f880-43df-b808-451e3a1eab18.

[32] Ellison, Ayla. “Steward Health Care Sues Massachusetts to Avoid Financial Disclosures.” Becker’s Hospital Review, November 1, 2017. https://www.beckershospitalreview.com/finance/steward-health-care-sues-massachusetts-to-avoid-financial-disclosures.html.

[33] “Steward Health Care Finalizes Public-Private Partnership Agreement To Provide Health Care In Malta: Steward Corporate,” February 20, 2018. https://www.steward.org/steward-health-finalizes-partnership-malta.

[34] Dayal McCluskey, Priyanka. “As Hospitals Cut Maternity Services, Burden Is on Expectant Mothers – The Boston Globe.” The Boston Globe, March 27, 2018. https://www.bostonglobe.com/metro/2018/03/27/expectant-moms-must-travel-farther-community-hospitals-cut-maternity-services/BvaDGPEyUKLbZYE0xJzEfJ/story.html.

[35] “Pg. 78; (2018) Form 10-K Medical Properties Trust, Inc. MPT Operating Partnership, L.P.” Medical Properties Trust, March 1, 2019. https://medicalpropertiestrust.gcs-web.com/static-files/deb797d1-f880-43df-b808-451e3a1eab18.

[36] Bartlett, Jessica. “Steward Health Care Officially Moves HQ to Dallas.” Boston Business Journal, August 28, 2028. https://www.bizjournals.com/boston/news/2018/08/28/steward-health-care-officially-moves-hq-to-dallas.html.

[37] 21 WFMJ. “Job Losses Jump to 468 at Northside Regional Medical Center – WFMJ.Com,” August 17, 2018. https://www.wfmj.com/story/38909561/job-losses-jump-to-468-at-northside-regional-medical-center.

[38]WKBN News. “Northside Regional Medical Center in Youngstown Closing.” August 15, 2018. https://www.wkbn.com/news/local-news/northside-regional-medical-center-in-youngstown-closing/.

[39] steward.org. “Steward Health Care Launches New Subsidiary Offering Liability Protection: Steward Corporate,” February 21, 2019. https://www.steward.org/newsroom/2019-02-21/steward-health-care-launches-new-subsidiary-offering.

[40] “Steward Health Care Completes Acquisition of Scenic Mountain Medical Center: Scenic Mountain | A Steward Family Hospital | Big Spring TX.” Accessed May 20, 2024. https://www.scenicmountainmedical.org/domain-specific/720191/newsroom/2019-04-15/steward-health-care-completes-acquisition-scenic.

[41] Pg. 123 of “(2023) Form 10-K Medical Properties Trust, Inc. MPT Operating Partnership, L.P.” Medical Properties Trust, February 29, 2024. https://medicalpropertiestrust.gcs-web.com/static-files/d9b3ac66-d094-4db7-ba1c-8652b0b231ca.

[42] “Steward Health Care Opens Florence Hospital: Florence | A Steward Family Hospital | Florence AZ.” Accessed May 22, 2024. https://www.florencehospital.org/domain-specific/720191/newsroom/2019-09-26/steward-health-care-opens-florence-hospital;

[43] Pg. 125 of “(2023) Form 10-K Medical Properties Trust, Inc. MPT Operating Partnership, L.P.” Medical Properties Trust, February 29, 2024. https://medicalpropertiestrust.gcs-web.com/static-files/d9b3ac66-d094-4db7-ba1c-8652b0b231ca.

[44] Ellison, Ayla. “2 Arizona Hospitals Abruptly Close after Entering Bankruptcy.” Becker’s Hospital Review, June 18, 2018. https://www.beckershospitalreview.com/finance/2-arizona-hospitals-abruptly-close-after-entering-bankruptcy.html.

[45] Ellison, Ayla. “Arizona Hospital Closure Will Result in 655 Layoffs.” Becker’s Hospital Review, November 21, 2019. https://www.beckershospitalreview.com/finance/arizona-hospital-closure-will-result-in-655-layoffs.html.

[46] Spegele, Brian, and Laura Cooper. “As Coronavirus Cases Climbed, Private-Equity-Owned Hospital Demanded Bailout.” WSJ, April 26, 2020, sec. Markets. https://www.wsj.com/articles/as-coronavirus-cases-climbed-private-equity-owned-hospital-faced-closure-11587893400.

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