Banner Health's academic medical center in Phoenix. Photo: Banner Health

The number of hospital admissions, surgeries and other medical procedures has continued to stay flat in many parts of the country, but that hasn't prevented hospitals from retaining large sums of money and hiring more people.

The big picture: America's rural hospitals are dying. But large not-for-profit hospital systems in cities and suburbs are doing extremely well as premiums rise and as patients struggle to afford their medical bills.

Details: Axios analyzed the financial statements of 31 prominent not-for-profit hospital systems for the first 3 months of 2019.

  • This sample collectively generated $68.5 billion of revenue in the first quarter of this year. That's $274 billion annualized, or more than one-fifth of all hospital spending.
  • The combined operating margin was 5.1%, compared with 4.5% in the first quarter of 2018.
  • The combined net margin (after factoring in investment income) was 16.4%, a large jump from 5.5% in 2018.
  • These margins are on par with some pharmaceutical and medical device companies, and well above the margins for insurers and drug distributors.

Between the lines: Hospitals are feasting on bigger investment returns, boosted by the stock market's run, but they also are profiting more from commercial and public health insurer payments.

The intrigue: Not-for-profit hospitals don't pay taxes and don't have "shareholders" like publicly traded companies, so they are required to reinvest any surplus cash into their communities.

Case in point: Newly opened patient towers at Banner Health's academic medical center campuses in Arizona cost $1 billion and "are expected to drive additional volume increases," Banner said in a memo last week to bondholders. Banner declined an interview request.

  • "It's clear the hospital industry today continues to be driven by volume, which is where the big returns are," said Paul Ginsburg, director of the USC-Brookings Schaeffer Initiative for Health Policy. "Value-based [payment] approaches conflict with that."

Go deeper: Hospitals are making a fortune on Wall Street

Go deeper

Updated 34 mins ago - Politics & Policy

Coronavirus dashboard

Illustration: Sarah Grillo/Axios

  1. Global: Total confirmed cases as of 3 a.m. ET: 30,782,337 — Total deaths: 957,037— Total recoveries: 21,032,539Map.
  2. U.S.: Total confirmed cases as of 3 a.m. ET: 6,764,962 — Total deaths: 199,258 — Total recoveries: 2,577,446 — Total tests: 94,211,463Map.
  3. Politics: In reversal, CDC again recommends coronavirus testing for asymptomatic people.
  4. Health: The dwindling chances of eliminating COVID-19.
  5. World: Guatemalan president tests positive for COVID-19 — The countries painting their pandemic recoveries green.

The positions of key GOP senators on replacing Ruth Bader Ginsburg

Senate Majority Leader Mitch McConnell talks to reporters on Capitol Hill last Thursday. Photo: Chip Somodevilla/Getty Images

With President Trump planning to nominate his third Supreme Court justice nominee by next week, key Republican senators are indicating their stance on replacing the late Justice Ruth Bader Ginsburg just over six weeks out from Election Day.

The big picture: Senate Majority Leader Mitch McConnell (Ky.) has vowed that "Trump’s nominee will receive a vote on the floor of the United States Senate." But Sen. Lisa Murkowski (Alaska) told Alaska Public Media, "I would not vote to confirm a Supreme Court nominee. We are 50 some days away from an election."

Updated 2 hours ago - Politics & Policy

ActBlue collects a record $91 million in hours after Ginsburg's death

A makeshift memorial in honor of Justice Ruth Bader Ginsburg in front of the U.S. Supreme Court on Sept. 19. Photo: Samuel Corum/Getty Images

ActBlue received a record $91.4 million in the 28 hours following Supreme Court Justice Ruth Bader Ginsburg's death, the Democratic donation-processing site confirmed to Axios late Saturday.

Why it matters via the New York Times: "The unprecedented outpouring shows the power of a looming Supreme Court confirmation fight to motivate Democratic donors."