Not-for-Profit Healthcare Outlook Remains Negative

Goldstein says larger systems tend to be rated higher "because we see safety in numbers, strength in size, and critical mass."

"That being said we work with many small- to medium-sized hospitals that will demonstrate to us that because they are smaller they are very nimble and can make decisions more quickly and launch those strategies and execute on those strategies," Goldstein says.

"It is very much a broad statement to say larger equals better debt servicing. Although at the end of the day most of the large systems have higher ratings than the medium- and small-sized credits because they have gained efficiencies from their size of scale," she says.

"They usually have more leverage when dealing with third-party vendors and payers. One of the strengths we see in being large is they typically have a portfolio of hospitals and strong diversification of cash flow. Whereas if you are small and single site, if there is a tornado in that town you have no other facilities in the town to compensate if that particular facility is damaged."