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

$250 million

Saint Luke’s Health System
Tax-Exempt Fixed Rate Revenue Bonds, 2016

On May 5, 2016, RBC Capital Markets priced, as senior book-running manager, a $250 million tax-exempt fixed rate issue for Saint Luke’s Health System (“Saint Luke’s” or the “System”). Saint Luke’s is the largest not-for-profit health system in Kansas City with nearly $1.5 billion in operating revenue. Proceeds advance refunded Saint Luke’s Series 2003 and 2005 fixed rate bonds and converted a portion of the System’s variable rate debt to fixed rate

The order book was broadly distributed and included over 50 different institutional investors. Overall, Saint Luke’s achieved an all-in interest cost of 3.13% on an average life of 15.1 years. The refunding issue resulted in $31.8 million of present value savings, or 14.1% of the refunded par amount, and lowered the System’s maximum annual debt service by $2.2 million through the restructuring of the Series 2012 variable rate bonds. Three serial bonds and sole term bond sold at lower coupons: 4.00% 2042 term bonds had a yield-to-maturity 28 bps lower than conventional 5.00% coupon bonds.

$100 million

BJC Healthcare
Conversion of Series 2013C Windows Bonds to
Long-Term Rate Period

On June 9, 2016, RBC Capital Markets priced as sole remarketing agent a conversion of BJC HealthCare’s $100 million tax-exempt Windows variable rate bonds to a fixed rate, long-term rate period. The 2013C Windows Bonds came under pressure in late 2015 as demand for the money market fund product dwindled and the pricing spread over the SIFMA Index widened

RBCCM presented a unique solution to remarket the bonds using a reoffering circular which allowed the deal team to enter the market only three weeks after being mandated. RBCCM structured the conversion as two term bonds with coupons of 4.00% and 3.25% in order to minimize the higher yield-to-maturity associated with a conventional 5.00% coupon bond carrying a 10-year par call redemption feature. On the day of pricing, tax-exempt yields continued to rally and outperform Treasury yields as the 30-year “AAA” MMD yield opened at 2.34%, a new all-time low at the time of pricing. With the conversion, 11 new institutional investors were introduced to the BJC credit, a strong new following given the size of the offering. RBCCM’s successful conversion of BJC’s Series 2013C Bonds resulted in a blended interest cost of 3.53% for a 30-year non-amortizing bond. Compared to a conventional 5.00% coupon, BJC’s yield-to-maturity was 31bps lower on the 4.00% coupon bond and 55bps lower on the 3.25% bond. Overall, the utilization of the lower coupon bonds resulted in $5.8 million in present value debt service savings for BJC.

$352 million

Fairview Health Services
Privately Placed Taxable Bonds


Fairview is an integrated academic healthcare system located in Minnesota with $3.5 billion in annual revenue. This transaction was launched as an amortizing structure with a 28-year final maturity and 15.5-year average life. The initial offering was well received with interest from 13 investors. Fairview upsized the transaction to $352 million and priced the notes with a 15.5-year average life at +165bps with a 4.16% coupon. Proceeds used to redeem existing debt not eligible to be advance refunded on a tax-exempt basis. Fairview is rated A2 by Moody’s and A+ by S&P translating to an NAIC-1 rating in the private placement market.

Our Team

Adrian Balderrama

Head of Healthcare


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).


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.


Safi Najdawi



Jenn Ewing

Vice President
New York