Our Healthcare Finance Group partners with clients in the not-for-profit healthcare and higher education sectors to help them deliver high quality health services and facilities to best serve the changing needs of their communities. From multi-billion dollar national healthcare systems to local hospitals, our experienced team is prepared to provide seamless financings and ongoing investment banking services to clients well into the future. Our dedication to consistent senior coverage and exceptional client service has made us one of the nation’s leading underwriters of tax-exempt healthcare revenue bonds.

Areas of Expertise

Our committed and experienced team of healthcare finance professionals have extensive expertise in the areas of investment banking, underwriting, credit and distribution.

  • Leading underwriter of tax-exempt healthcare bonds
  • Senior bankers with over 25 years of healthcare finance experience
  • Significant and recent experience providing first in class service and innovative solutions to numerous healthcare systems
  • Comprehensive corporate investment banking and research capability
  • Ability to provide balance sheet products and derivative solutions from a stable and highly-rated counterparty
  • Broad distribution platform reaching all investor segments

We offer a full range of services to meet all the investment needs of
nonprofit healthcare corporations and higher education institutions.

Case Studies

$291.38 million

Industrial Development Authority of the County of Maricopa
HonorHealth (AZ)
Hospital Facilities Revenue Refunding Bonds,
    •  $195 million Series 2019A Tax-Exempt Fixed Rate Bonds
    •  $45 million Series 2019B Long-Term Bonds
    •  $50 million Series 2019C Floating Rate Notes
RBCCM Role: Lead Manager

Transaction Summary

On December 4, 2018, RBC Capital Markets served as lead manager on HonorHealth’s (“Honor” or “Health System”) $291 million tax-exempt transaction revenue bonds, issued through the Industrial Development Authority of the County of Maricopa. The Series 2019 transaction, was comprised of $196 million Series 2019A fixed-rate tax-exempt bonds, $45 million Series 2019B tax-exempt put bonds, and $50 million Series 2019C floating rate notes (together the “Bonds”). The Bonds received public ratings of “A2” (Stable) by Moody’s and “A” from Fitch with a revised outlook from “Stable” to “Positive”.

The purpose of the transaction was to refinance the Series 2008A bonds, restructure the Series 2014 direct placement bonds, and fund $200 million of capital expenditures including $120 million dedicated to the construction of Honor’s Sonoran Medical Center. The strategic initiative to expand the Sonoran Campus with the new acute care hospital adds much needed inpatient capacity to an existing free standing emergency center with ambulatory services – in a growing market with no nearby hospitals.

This marks HonorHealth’s inaugural transaction following the merger of John C. Lincoln and Scottsdale Healthcare on January 1, 2015. The RBCCM banking team has maintained a relationship with management dating back to 2014. The banking team’s mandate is attributable to consistent investment banking coverage including an integral role in HonorHealth’s investor marketing and rating process over the last several years.

Series 2019 Transaction Details

Issue Size: $281,380,000
Issuer: Industrial Development Authority of the County of Maricopa
Borrower: HonorHealth
Offering: Tax-Exempt Revenue Bonds
Ratings: Moody’s: A2 (stable) / Fitch: A (Positive)
Structure: Fixed Rate Bonds, Put Bonds, and Floating Rate Notes
Optional Call Provision: 10-Year Par Call (Series 2019A)
Pricing Date: December 4, 2018
Closing Date: January 3, 2019
All-In Interest Cost: 3.77%
Average Life: 19.2 years
Lead Manager: RBC Capital Markets

Overview of HonorHealth

HonorHealth, together with its affiliates, own and operate a healthcare system that serves the greater Phoenix, AZ area. The $1.7 billion Healthcare System consists of five acute care hospitals, a captive insurance company, ambulatory care centers, two accountable care organizations, medical practices, a foundation, and an organization titled Desert Mission, which provides family services, child services, and health services for low income families. Honor maintains over 1,300 licensed beds and over 3,700 affiliated physicians, 32 primary care locations, and serves nearly 65,000 inpatient admissions. HonorHealth has the highest market share in its primary service area with approximately 32%.

The proceeds of the 2019 transaction HonorHealth will expand the Sonoran campus by completing the constructing of their 79 bed acute care hospital. The new system, located in north Phoenix - marked as a growing and affluent part of metropolitan Phoenix - will be known as the HonorHealth Sonoran Medical Center expected to be completed in September 2020.

Overview of Transaction

The goal of the financing was to (i) refinance Honor’s Series 2008A bonds, (ii) restructure Honor’s Series 2014 direct placement bonds, and (iii) fund up to $200 million of capital projects. In order to target a debt mix of 20-25% variable rate (including put bonds) Management elected to issue approximately $200 million of fixed rate bonds, approximately $50 million of put bonds, and $50 million FRNs, with the option to upsize the put bonds depending on the receptivity of the FRN market. Following the engagement in late September, the financing team assisted with Honor’s Board Meeting presentations, credit rating process, and the crafting of their Appendix A.

With the New Year fast approaching, the underwriting team set forth with a fairly aggressive financing timeline with a four day marketing period following the posting of the offering document on Wednesday, November 28th and pricing scheduled for the following Wednesday, December 5. The three-part marketing phase of the transaction included a “live” investor roadshow presentation, an investor brunch in Boston, and 16 one-on-one meetings with individual funds from Friday, December 29th to Tuesday, December 4th. Following the unplanned closing of the bond market on Wednesday, December 5 (the initial pricing day) in recognition of the passing of President George H.W. Bush, the financing team acted expeditiously to accelerate the pricing to Tuesday, December 4, ahead a $9.3 billion negotiated calendar.

The previous week’s market tone was driven by dovish comments from the Fed, and ongoing trade worries from Capitol Hill. Despite a rally in equities mid-week, fixed income yields continued to move generally lower following the Fed’s announcements, with Municipals outpacing Treasuries. On the day of pricing, MMD was unchanged across the curve from the previous reset. The tone of the tax-exempt market was soft with the primary focus on the anticipated $9.3 supply calendar (returning to more normalized levels) following a quiet thanksgiving week.

The RBCCM underwriting team opened the order period with an aggressive pre-pricing wire after indications from various investors. The 2042 final maturity on the fixed rate series was bifurcated with $20 million allocated to 4.125% bonds and the remaining $37 million allocated to 5.00% coupon bonds. At the request of the client, the underwriting team proceeded with the FRNs with whispers of interest from Franklin, Nuveen and Wells Capital. After a three hour order period, the transaction was completed with over $2.0 billion in orders (7x subscribed) from a diversified book of 50 investors including 36 new names to the credit. The pricing levels on the Series A fixed rate bonds were bumped 7-13 basis points (“bps”) with the 2019-2042 yields ranging from 3.36-3.88% on the 5.00% coupons and 4.15-4.20% on the 4.125 coupons. The Series B put bonds were bumped 2 bps for a final yield of 2.76%. Additionally, RBCCM’s underwriting team garnered interest to complete the FRN order book at the same pre-pricing levels. The Series C FRNs were priced to SIFMA with a spread of 80 bps.

HonorHealth’s was able to price the transaction at an all-in TIC of 3.77% including $1.8 million in savings (5.4% of refunded par) on the Series 2008A bonds and obtain overall aggregate level debt service on their bond portfolio with MADS only increasing by $5.4 million. The Management team was very happy with the outcome.

GIB - Municipal Finance

Adrian Balderrama (602) 381-5367 adrian.balderrama@rbccm.com
Jenn Ewing (212) 301-1435 jennifer.ewing@rbccm.com
Francis Adarkwa (312) 362-4136 francis.adarkwa@rbccm.com
Blake Pinell (212) 301-1438 blake.pinell@rbc.com

Municipal Markets

David Grad (312) 559-1658 david.grad@rbccm.com
Traci Radochonski (312) 559-1631 traci.radochonski@rbccm.com

$305.684 million

Mercy Health
Part of Bon Secours Mercy Health
Taxable Bonds, Series 2018A

Up to $50,000,000

Mercy Health
Part of Bon Secours Mercy Health
Taxable Commercial Paper Notes, Series 2018B

RBC Roles: Joint-Bookrunner and Commercial Paper Dealer

Overview of Bon Secours Mercy Health

On September 1, 2018, Mercy Health combined with Bon Secours Health System, Inc. (“BSHSI”) and BSHSI changed its name to Bon Secours Mercy Health, Inc. (“BSMH” or “Bon Secours Mercy Health”). On that date, BSMH was substituted as the sole corporate member of Mercy Health. BSMH serves communities throughout Florida, Kentucky, Maryland, New York, Ohio, South Carolina and Virginia at over 1,000 sites of care, including 42 acute care hospitals and more than 50 home health agencies and senior health and housing facilities. The combined entity has annual revenues of $8.1 billion and unrestricted liquidity of $3.9 billion.

Transaction Summary

On December 10, 2018, RBC acted as joint-bookrunner on a $306 million taxable financing for BSMH, and on December 14, RBC, in its role as commercial paper dealer initiated a $50 million taxable commercial paper program for BSMH. These transactions, in combination with 2 privately placed bank loans move all BSHSI debt under the Mercy MTI and effectively consolidates the capital structures of the two legacy systems. Series 2018AB is Bon Secours Mercy Health’s inaugural public market financing post-merger.

Series 2018 Taxable Bonds:

Size: $305,684,000
Ratings: Moody’s: A2 (pos) / S&P: A+ / Fitch: AA-
Term: 9.5-years
Coupon: 4.302%
Pricing Date: December 10, 2018
Joint-Bookrunners: JP Morgan and RBC Capital Markets

Series 2018B Taxable Commercial Paper Notes:

Size: $50,000,000
Ratings: Moody’s: P-1 / S&P: A-1 / Fitch: F1+
Maturity Date: 1 – 270 Days
Credit Facility: Self Liquidity
Pricing Date: December 14, 2018
Dealer: RBC Capital Markets

Marketing and Pricing

The week initially slated for pricing the taxable bond issue was especially volatile with markets halted for George H.W. Bush’s funeral and further affected by on-going trade discussions with China and uncertainty regarding a December Fed rate hike. The syndicate, after careful consideration of market tone and direction, elected to delay entering the market and to approach investors the following week. Investor demand proved strong the following week as the syndicate successfully garnered $542 million of orders across 16 institutional investors for an oversubscription of 1.8x, allowing the underwriters to reduce the transaction's final spread by 5 bps to + 145 bps over the 10 Year UST (4.302%).

BSMH selected a 30-day term for its first Series 2018B CP roll - RBC’s short-term desk secured a rate of 2.65% or a spread of 20 bps to 1-Month LIBOR, committing $20 million of firm capital to support the transaction.

Relationship Overview

The banking team has enjoyed a longstanding relationship with the legacy Mercy Health finance team dating back to 2010. The banking team most recently served as joint-bookrunner on Mercy Health’s Series 2017ABC financing while at their prior firm. Upon BSHSI and Mercy’s consolidation, the Mercy Health finance team assumed responsibility for capital markets activities of the newly formed system. This is BSMH’s first transaction post-merger and is the first assignment for RBC with either of the legacy health systems.

Please address any questions to the following members of the coverage and transaction team:

GIB - Municipal Finance

Adrian Balderrama (602) 381-5367
Safi Najdawi (215) 832-1519
Jenn Ewing (212) 301-1435
Blake Pinell (212) 301-1438
Ashley Shields (212) 905-5907

FICC – Taxable Municipal Capital Markets

Glenn McGowan (212) 519-8415
Donna Baldino (212) 618-5621

FICC – Short-Term Municipal Capital Markets

Craig Laraia (212) 618-2019
Marlar Oo (212) 618-2023

Corporate Banking

Jake Sigmund (212) 428-7925
John Wells (212) 428-2331

Our Team

Adrian Balderrama

Head of Healthcare
Managing Director


Mr. Balderrama is the Head of RBC Capital Markets’ Not-For-Profit Healthcare Investment Banking group. He has over 15 years of banking experience with the majority of his career being focused in healthcare finance. His primary role includes leadership of the national healthcare team, accessing the municipal and corporate bond markets, rating agency and investor communication, and various advisory functions to support his client base. He works closely with a wide variety of health systems ranging from large multi-state health systems, children’s hospitals, and regional health organizations.

Prior to joining RBC Capital Markets, Mr. Balderrama Co-Managed Wells Fargo Securities Not-For-Profit Healthcare Investment banking practice. Under Mr. Balderrama’s time at Wells Fargo, the team doubled their market share to become a Top 5 lead manager of transactions. Notable clients include Kaiser Permanente, Dignity Health, Mercy Health (OH), SSM Health, and Intermountain Health, among others.

Mr. Balderrama works closely with several Not-For-Profit charity organizations and was a past board member of the Phoenix Boys and Girls Club of America. He holds a Bachelor of Science in Finance from the University of Arizona.


Jerry Berg

Managing Director


Mr. Berg joined RBC in 2012 after having worked at Morgan Stanley for five years. Prior to Morgan Stanley, Mr. Berg spent 18 years with UBS/PaineWebber, beginning as an associate in New York and progressing to Managing Director responsible for Healthcare Banking in the Mid-West region in the Chicago office.

Mr. Berg has worked for a mix of clients including academic medical centers, multi-state systems, regional tertiary care facilities, community hospitals and specialty children’s hospitals.  He has completed financings across the project and credit spectrum from self-liquidity variable rate demand bond financings for “AA” health systems to replacement hospital financings for “BBB” community hospitals.  He has strategic experience involving joint operating agreements and full-asset mergers for acute care hospitals as well as merger and acquisition activity involving provider sponsored managed care companies. Mr. Berg’s client relationships include: Saint Luke’s Health System (MO), BJC HealthCare (MO), Fairview Health Services (MN), Covenant Health (MI), ProHealth Care (WI), Mercy Medical Center (IA), Southern Illinois Healthcare (IL) and Lakeland Health System (MI).

Mr. Berg earned a B.S. degree from Southern Illinois University and an M.B.A. degree and a Certificate from the Sloan Program in Health Services Administration from Cornell University. Mr. Berg is a Certified Public Accountant (CPA).


Teri Hartman

Managing Director


Teri has over 30 years of experience in healthcare investment banking, for the most part in Atlanta, serving multi-state, single state, super-regional health systems, academic medical centers and children’s health systems.

Teri is joining us from Barclays where she was a Managing Director and Co-Head of its Not-For-Profit Healthcare Banking group. Prior to Barclays, Teri was a Managing Director and Head of the Southeast Not-For-Profit Healthcare Banking group at Citigroup. A graduate of Duke University, Teri started her investment banking career at Bankers Trust. Teri holds Series 7, 52, 53, 63, 79 and SIE licenses.

Outside of work Teri keeps herself busy as a board member of Children’s Healthcare of Atlanta, the Boys and Girls Clubs of Metro Atlanta, the Rotary Club of Downtown Atlanta, and Healthcare Georgia Foundation.


Jeff Appel



Mr. Appel is a Director within RBCCM’s Healthcare Finance Group and has been involved in over $3 billion of healthcare financings since he joined RBCCM in 2002. Mr. Appel has worked with some of the Nation’s leading academic medical centers such as UPMC, BJC HealthCare and Fairview Health Services. He recently worked directly with BJC HealthCare on their $500 capital funding program that included the use of self-liquidity backed Windows variable rate bonds, long-term fixed rate bonds and privately placed floating rate notes.  He is well versed on the use of self-liquidity backed structures and best practices regarding self-liquidity disclosure. In addition, he worked directly with UPMC as senior managing book-runner for their $550 million tax-exempt and taxable fixed rate bond offerings. 

Over the course of his career, Mr. Appel has been involved in a variety of healthcare financings, including complex fixed and floating rate bond structures, interest rate derivative and forward structures and other unique financing alternatives.  Mr. Appel has structured and executed innovative transactions for a number of RBCCM healthcare clients including Memorial Hermann Healthcare System (TX), Saint Luke’s Health System (MO), The Christ Hospital (OH) and the Texas Medical Center, among others. 

He received a B.A. degree from the University of Colorado, Leeds School of Business with a major in Finance and has passed Level I of the CFA examination.  He currently holds his FINRA Series 7, 63, and 65 licenses.


Jenn Ewing

New York


Jenn Ewing Joined RBC Capital Markets in 2018 as a Vice President on the Not-for-Profit Healthcare Investment Banking team to provide support on credit strategy with rating agencies and investors. She has a broad experience in healthcare spanning over 20 years. Prior to joining RBC, Jenn held a similar position at Wells Fargo Securities, where she helped position hospitals and health systems to obtain and maintain optimal ratings and strong investor reception. Prior to this role, Jenn was a member of Moody’s Healthcare Ratings team as lead analyst responsible for rating not-for-profit hospitals and health systems across the US and authoring multiple publications including Moody’s 2015 Not-For-Profit Healthcare Rating Methodology. Prior to Moody’s, Jenn was a physical therapist and served as a regional manager in Manhattan for numerous outpatient physical therapy clinics for HealthSouth and Sports Physical Therapy of New York, PC. She received her B.S. from Duke University, M.P.T. from Emory University, and M.P.A. from the Wagner School of Public Service at New York University specializing in public finance.


Safi Najdawi



Mr. Najdawi is a Director within RBC Capital Markets’ Not-for-Profit Healthcare Investment Banking group. He has over 11 years of investment banking experience in the sector. His primary role includes debt capital markets advisory within the tax-exempt municipal and corporate taxable bond markets. In addition to his primary function in debt capital markets advisory, Mr. Najdawi’s expertise includes financial statement and debt capacity analysis, merger and acquisition evaluations, and the coordination of investor dialogues, on a transactional or on-going basis, from marketing through final sale.

Prior to joining RBC Capital Markets, Mr. Najdawi spent 11 years at Wells Fargo Securities, most recently as a Director within the Not-for-Profit Healthcare Investment Banking practice.

Prior to his time at Wells Fargo Securities, Mr. Najdawi was employed at leading software provider, SAP, at the company’s U.S. Headquarters. A graduate of Villanova University, he competed on the nationally-ranked NCAA Division 1 Lacrosse team. He holds FINRA Series 7, 63, 79 licenses.