General Medical and Surgical Hospitals (U.S.) — NAICS 622110

An investor's primer. NAICS = North American Industry Classification System, the U.S. government's standard code for industries.

1. Overview

General medical and surgical hospitals are the acute-care anchors of American health care: the buildings with emergency departments, operating suites, intensive-care units, and inpatient beds where people go for surgery, childbirth, heart attacks, strokes, and other serious illness. They also run large outpatient, imaging, laboratory, and pharmacy operations. Hospital care is the single largest line item in U.S. health spending — it reached roughly $1.5 trillion in 2023, about 31% of all national health spending, and grew about 10.4% that year, the fastest pace in decades.[6]

Three features make this industry unusual for an investor. First, demand is largely non-cyclical: people get sick regardless of the economy. Second, the patient who receives the service rarely pays the bill directly — government programs and insurers do, which makes payment policy, not consumer demand, the dominant variable. Third, most of the industry is not for-profit and cannot be bought as a stock: roughly three-quarters of U.S. community hospitals, and around 80% of beds, sit in nonprofit or government hands.[5]

A theme runs through everything below: the economics are local. National chains provide scale, but a hospital's pricing power, staffing, service mix, and competitive strength are usually set in its individual metropolitan or rural market. Public-market investors can own a handful of large for-profit operators (HCA, Tenet, Universal Health Services, Community Health Systems, Ardent) plus a couple of hospital landlords. Private investors reach the sector through private equity, private credit, joint ventures, hospital real estate (sale-leasebacks), and — the biggest single door into the nonprofit majority — tax-exempt municipal debt.

2. What it is and how it's structured

NAICS 622110 covers establishments licensed as general medical and surgical hospitals — those providing inpatient diagnostic and medical treatment for a wide range of conditions, with both surgical and non-surgical care, typically backed by an emergency department, diagnostic imaging, labs, pharmacy, and food and housekeeping services. A hospital can also run outpatient surgery, imaging, and clinics and still fall in this category.[1]

What it excludes (adjacent codes an investor should not conflate):

• 622210 — Psychiatric and Substance Abuse Hospitals (behavioral-only facilities).[1]
• 622310 — Specialty (except Psychiatric and Substance Abuse) Hospitals — children's, cancer, rehabilitation, and long-term acute-care hospitals.[1]
• 621111 — Offices of Physicians, and other 621 ambulatory services, including freestanding ambulatory surgical and emergency centers (621493) and other outpatient care centers (621498) — the fast-growing ASCs (ambulatory surgery centers, where surgery is done without an overnight stay).[1]
• 623110 — Nursing (skilled-nursing) Facilities and other residential care.[1]

Some public companies straddle these lines: Universal Health Services runs both acute-care hospitals (622110) and a large behavioral division (622210), and Tenet pairs its hospitals with the country's largest ASC platform (621). No listed operator is a pure 622110 play.

Ownership mix. The American Hospital Association (AHA) counts about 5,112 community hospitals: roughly 2,978 nongovernment nonprofit, 1,214 investor-owned (for-profit), and 920 state or local government hospitals.[5] Nonprofits dominate — they operate under a 501(c)(3) tax exemption (a federal tax-exempt status for charitable organizations) in exchange for providing "community benefit" and charity care. For-profits are a minority of hospitals but the only meaningful equity investments. A further wrinkle: the operating company often does not own the building. Hospitals are frequently leased from real-estate owners or run through majority-owned joint ventures with physicians, universities, or nonprofit systems, so "who owns the hospital" and "who owns the cash flow" can be different questions.[14][15]

3. How big it is

Federal statistics for NAICS 622110 (dollar amounts converted from the source's thousands-of-dollars units):

(The HHI is a standard 0–10,000 market-concentration gauge; the SBA — Small Business Administration — size standard is a procurement-classification threshold, not a measure of industry size.)

At ~5.8 million workers, this one six-digit industry employs roughly one in every 28 U.S. jobs — among the largest private employers in the entire economy.[2]

The undercount caveat. County Business Patterns and the Economic Census largely exclude government-owned hospitals (state, county, city, and federal facilities such as Veterans Affairs and military hospitals); Census publishes government hospitals separately.[2][3] Because about 920 community hospitals — plus the entire federal system — are government-run, the true acute-care footprint is larger than these business counts suggest.[5] Read the $1.27 trillion receipts figure (2022) alongside CMS's broader "hospital care" spending of ~$1.5 trillion (2023), which captures all hospital types including government and specialty facilities.[6] (CMS = Centers for Medicare & Medicaid Services, the federal health-financing agency.)

What the federal file does not give us. There are no industry-wide figures here for beds, occupancy, admissions, payer mix, operating margins, or capital spending — those should not be inferred from the numbers above. Where this primer cites such metrics, they come from company filings and industry research, not the Census file.

4. The investable universe

Most hospital capacity is off-limits to stock investors. The public equity plays are a small set of for-profit operators plus a couple of landlords.

Public operators (operational counts from the most recent Form 10-K annual reports; revenue is fiscal-year 2024):

(REIT = real estate investment trust, a company that owns income property and passes most profit to shareholders. IPO = initial public offering, a company's stock-market debut.) A second, smaller hospital landlord, Universal Health Realty Income Trust (NYSE: UHT), also offers real-estate rather than operating exposure.[36]

The much larger private / other side. The biggest hospital systems in the country are nonprofits you cannot buy shares in: Kaiser Permanente (~$115.8B revenue, an integrated insurer-provider), CommonSpirit Health (~$37B), Advocate Health (~$31.7B), Ascension (~$28.6B), and Trinity Health (~$23.9B), alongside Providence, Mayo Clinic, Cleveland Clinic, UPMC, Intermountain Health, and Baylor Scott & White.[10] These systems finance themselves largely through tax-exempt municipal bonds, so fixed-income investors — not equity investors — are the main outside capital in the nonprofit majority. Private for-profit owners include LifePoint Health (controlled by funds affiliated with Apollo Global Management; it grew to about 68 community-hospital campuses after buying eight acute-care hospitals from ScionHealth in 2026)[16] and physician-founded Prime Healthcare.[15] Because private ownership usually splits across an operating company, a real-estate owner, a physician group, and lenders, a private investor must pin down exactly which entity owns the cash flow being bought.

5. How the money works

A hospital's revenue is, in effect, volume × acuity × price, summed across inpatient admissions, outpatient visits, emergency visits, and surgeries. Reported patient-service revenue is stated net of contractual discounts and estimated payer adjustments — not the hospital's list-price charges.[13]

• Volume — admissions and, because outpatient care now rivals inpatient, "adjusted admissions" that fold in outpatient activity. The for-profits report same-facility (or "same-hospital") admission and revenue growth — the hospital equivalent of "same-store sales" in retail and the cleanest read on organic health.[7]
• Acuity — the sickness/complexity of cases, captured by the case-mix index; sicker patients bill more.
• Price — set almost entirely by the payer, not the patient.

Payer mix is the single biggest profit lever. Each patient falls into a bucket:

• Medicare (age 65+ and some disabled) pays fixed, administratively set rates. Inpatient stays are paid per DRG (diagnosis-related group) under the IPPS (Inpatient Prospective Payment System) — a flat sum for the diagnosis, adjusted for severity (the Medicare Severity DRG, or MS-DRG), labor costs, geography, and teaching status — so efficiency is rewarded and long stays are penalized.[18] Outpatient care is paid under a parallel system, the OPPS (Outpatient Prospective Payment System).[19]
• Medicaid (low-income, state-run with federal money) usually pays the least, often below cost.
• Commercial insurers (employer and individual plans) pay negotiated rates that typically run substantially higher than either government program — they cross-subsidize the rest.
• Self-pay / uninsured patients frequently cannot pay, producing uncompensated care. Medicare Advantage (privately run Medicare) plans add their own negotiated rates and collection friction.

Because commercial payers pay so much more per case, they punch above their weight in revenue: in one large industry sample, commercial and self-pay accounted for roughly 70% of net patient revenue, versus about 15% each for Medicare and Medicaid — even though the government programs cover a very large share of actual patients.[17] A hospital rich in commercially insured patients is profitable; one dependent on Medicaid and the uninsured often is not. This is why the same medical service can be a moneymaker in a suburb and a loss in a poor rural county.

Cost structure and the metrics that matter. Hospitals are high-fixed-cost businesses, so occupancy and throughput drive profitability (operating leverage cuts both ways). Labor is roughly half of expenses and the hardest to control; drugs, implants, supplies, and purchased services are the next biggest buckets.[20] Investors and bond-rating analysts watch operating margin and EBITDA margin (earnings before interest, taxes, depreciation, and amortization), same-facility volume, net revenue and labor cost per adjusted admission, payer mix, days cash on hand (a liquidity cushion), and lease-adjusted leverage. Nonprofit hospitals ran a median operating margin near 4.9% in 2024 — an improvement over the losses of 2022–2023, but thin.[20] For-profits earn more by concentrating in favorable commercial markets, leaning into higher-margin outpatient and surgical work, and using scale to buy supplies cheaply; HCA has posted double-digit operating margins that most nonprofits never approach.[7] Additional levers include the 340B drug-discount program (below) and supplemental Medicaid payments funded by state provider taxes.

6. What drives demand

• Demographics. An aging population is the durable tailwind — the 65-plus cohort uses far more hospital care and is the fastest-growing age group, even as overall population growth slows.[30]
• Medical intensity. More cardiovascular, oncology, orthopedic, neurological, and surgical care per person lifts spending independent of headcount.
• Insurance coverage. More insured people means fewer unpaid bills; coverage expansions (the Affordable Care Act, Medicaid growth) improved payer mix, and coverage losses reverse it.
• Acuity and utilization. The 2023 spending surge came mainly from sicker patients and more procedures, not higher prices.[6]
• Site-of-care shift (a headwind for inpatient). Care keeps migrating from the hospital bed to the outpatient department, the ASC, and the home (hospital-at-home, telehealth, urgent care). Inpatient volumes are flat-to-declining while ambulatory and surgical-center volumes grow — which is why Tenet and others are pivoting toward ASCs. This hurts systems that own only beds and helps those that also own the outpatient sites patients move to.[7]
• Cyclicality is indirect. Sickness doesn't track the business cycle, but payer mix does: recessions push people off commercial insurance onto Medicaid or into the uninsured pool, squeezing margins even when patient counts hold.

For context on scale, CMS's national health-spending projection — a whole-system forecast, not a NAICS 622110 forecast — has health spending growing about 5.4% a year from 2025 through 2034, versus about 4.1% for gross domestic product, with Medicare growing fastest (~7.7%).[6] A rising tide does not guarantee attractive hospital returns, because the fastest-growing payer (Medicare) generally pays less than the commercial insurance that drives margins.

7. Regulation

Hospitals are among the most heavily regulated businesses in America, and CMS is simultaneously the biggest customer and the chief regulator.

• Payment rules. CMS sets IPPS (inpatient) and OPPS (outpatient) rates each year; these annual updates directly move revenue.[18][19]
• Conditions of Participation. To bill Medicare, a hospital must meet CMS rules on governance, staffing, patient rights, infection control, emergency services, and facilities.[24]
• EMTALA (Emergency Medical Treatment and Labor Act, 1986). Any Medicare-participating hospital with an emergency department — nearly all of them — must screen and stabilize every emergency patient regardless of ability to pay. This guarantees access but is a structural source of uncompensated care.[21]
• 340B drug program. Requires drug makers to sell heavily discounted outpatient drugs to qualifying safety-net hospitals; the spread between the discount and reimbursement is a meaningful profit source, and a perennial political target.[22]
• No Surprises Act (2022). Bans most surprise out-of-network bills and routes provider–insurer payment disputes to independent arbitration.[23]
• Fraud-and-abuse laws. The Anti-Kickback Statute, the physician self-referral ("Stark") law, and the False Claims Act restrict referral payments, financial relationships, and improper government billing — a major compliance burden.[25]
• Privacy and cybersecurity. HIPAA (Health Insurance Portability and Accountability Act) imposes privacy and security duties on providers and their vendors.[25]
• Certificate of Need (CON) laws. In 35 states plus Washington, D.C. (as of January 2025), government approval is required before a hospital can be built, expanded, or add beds or major equipment — limiting new competition in those markets.[26]
• Price transparency. Hospital Price Transparency (HPT) rules require public machine-readable pricing files and consumer displays; new requirements took effect January 1, 2026, with enforcement from April 1, 2026.[27]
• Nonprofit tax exemption. Nonprofits must document community benefit and charity care to keep their 501(c)(3) status — an area of growing IRS and congressional scrutiny.[5]
• Antitrust. The Federal Trade Commission (FTC) and Department of Justice (DOJ) police hospital mergers (below).[28]

Regulation affects not just compliance cost but which services a hospital may offer, how fast it can expand, and what it can collect.

8. Competitive dynamics and consolidation

The defining feature: competition is local, not national. On paper the industry is fragmented — the top four firms hold just 8.4% of national receipts, the top 50 hold 34.6%, and the national HHI is a minuscule 37.6.[3] But patients don't choose a hospital in another city, so national numbers mislead. In local markets the picture reverses: by 2016 about 90% of metro areas were "highly concentrated" for hospital services, and by 2022 one or two systems controlled the entire inpatient market in nearly half of all metro areas.[29] In one 2024 case, the FTC alleged that a proposed acquisition would hand the buyer nearly 65% of local general-acute inpatient services.[28]

Decades of merging built that concentration, and research links it to higher prices — horizontal hospital mergers in already-concentrated markets have raised prices anywhere from 6% to 65%.[29] The current frontier is vertical and cross-market integration: systems buying physician practices, insurers (UnitedHealth's Optum) buying providers, and hospital systems combining across regions to gain leverage over insurers — a structure the FTC's local-market merger playbook struggles to challenge.[28][29]

Among the for-profits, strategies diverge. HCA is growing in strong markets; Tenet, CHS, and the collapsed Steward have been shrinking — selling hospitals to cut debt and refocus on outpatient (Tenet) or survival (CHS).[7][31] Scale genuinely helps purchasing, billing, and access to capital, but the value increasingly lies in a defensible local position rather than national size, precisely because antitrust review targets local dominance. Meanwhile ASCs, retail clinics, and telehealth keep pulling profitable outpatient volume away from the hospital campus.

9. Risks

• Policy / reimbursement risk is the top risk. Rates are set by government and insurers, not the market, and may not keep pace with costs. The 2025 budget law (the One Big Beautiful Bill Act, OBBBA / H.R. 1) cuts roughly $900 billion to $1 trillion from Medicaid over a decade via work requirements, provider-tax limits, and payment caps — a direct hit to hospital revenue and payer mix, phasing in from 2026.[32]
• Rural fragility. Nearly half of rural hospitals already run negative margins; estimates of how many face elevated closure risk under the Medicaid cuts range from roughly 440 to about 700 hospitals, and the law's $50 billion rural fund covers only a fraction of the projected loss.[32]
• Labor. Wages and clinical staffing shortages (nurses, physicians, technicians) remain the largest and stickiest cost pressure even after pandemic-era contract-nursing costs eased.[20]
• Payer friction. Rising claim denials and prior-authorization hurdles — especially from Medicare Advantage plans — delay and reduce payment; CHS cited payer denials among its 2024 loss drivers.[31]
• Leverage and financial engineering. Steward Health Care — 31 hospitals, previously private-equity-owned and loaded with sale-leaseback rent — filed one of the largest hospital bankruptcies in decades in May 2024, dragging down its landlord Medical Properties Trust and shutting hospitals. A cautionary tale for debt-heavy and PE-owned models.[33]
• Cybersecurity and operational shocks. The February 2024 Change Healthcare ransomware attack froze claims processing industry-wide and choked hospital cash flow, requiring more than $9 billion in emergency advances; ransomware also crippled nonprofit giant Ascension the same year.[34]
• Quality, liability, and local-market risk. Patient-safety failures bring litigation, penalties, and lost referrals; and a hospital can have little bargaining power even when its national parent is large.
• Macro sensitivity. High fixed costs, capital intensity, and heavy debt (for operators and for REIT lessees) make the sector sensitive to interest rates and to recessions that erode payer mix.

10. How to invest, and the outlook

Public-market routes. The direct plays are the for-profit operators: HCA (the blue-chip scale leader), THC (hospitals plus the leading ambulatory-surgery platform), UHS (acute plus behavioral), CYH (a turnaround / deleveraging story), and ARDT (a smaller 2024 debutant). MPW and UHT offer landlord (real-estate) rather than operating exposure — their returns hinge on tenant credit, rent coverage, and the ability to replace a failed operator, as the Steward saga showed. Before comparing valuations (e.g., enterprise value to EBITDA), adjust for differences in debt, leases, and non-hospital businesses — two operators with similar reported EBITDA can be economically very different once leases are counted. Diversified investors also get indirect exposure through health-care sector funds and through the insurers and outpatient operators adjacent to hospitals. Key things to examine: same-facility admissions and payer mix, contract-labor and staffing vacancies, denials and receivables, capital-spending plans, lease-adjusted leverage, and local-market concentration.

Private-market routes. Private equity owns hospitals directly (with a mixed-to-poor record) and is most active in the higher-growth adjacencies — ASCs, physician groups, imaging, revenue-cycle services, and post-acute care. Real-estate investors participate through hospital and medical-office sale-leasebacks, which raise cash but convert ownership into fixed rent (more operating leverage). The largest capital channel of all into the nonprofit ~80% of the industry is tax-exempt municipal bonds, rated by Moody's, S&P, and Fitch — the practical way to lend to Ascension, CommonSpirit, Trinity, and their peers. Private buyers should underwrite the individual hospital, not the brand: Is it the only acute-care provider in its market? What is the payer mix and the quality of its insurer contracts? Can it recruit clinicians and keep emergency coverage? Are rent, debt, or preferred claims already absorbing operating cash flow?

Outlook. Reported: national health spending is projected to grow faster than GDP through 2034, with Medicare growing fastest.[6] Margins recovered through 2024 (nonprofit median ~4.9%), but rating agencies expect renewed pressure into 2025–2026 from soft inpatient volumes and persistent labor costs.[20] Editorial judgment (a forward-looking view, not a reported fact): the long-term demand outlook is favorable but returns will stay highly uneven. The dominant forward variable is OBBBA's Medicaid cuts, which threaten payer mix and rural viability as they phase in.[32] The likely shape of the next few years is a widening gap between well-capitalized systems in strong commercial markets — which consolidate and invest in outpatient growth — and Medicaid-dependent and rural hospitals facing closure or forced sale. The best opportunities lie where an investor can separate durable local demand and pricing power from temporary distress, excess leverage, weak payer contracts, or underfunded capital needs.

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Sources

1. U.S. Census Bureau, "2022 NAICS Definition: 622110 General Medical and Surgical Hospitals" (and adjacent codes 622210, 622310, 621111, 621493, 621498, 623110). https://www.census.gov/naics/?details=622110&year=2022
2. U.S. Census Bureau, County Business Patterns, NAICS 622110 (2023); program coverage/methodology (employer establishments; excludes most government). https://www.census.gov/programs-surveys/cbp.html
3. U.S. Census Bureau, 2022 Economic Census — establishment/firm-size and concentration statistics, NAICS 622110 (firms, receipts, CR4/CR8/CR20/CR50, HHI; government hospitals published separately). https://www.census.gov/programs-surveys/economic-census.html
4. U.S. Small Business Administration, Table of Small Business Size Standards (2023). https://www.sba.gov/document/support-table-size-standards
5. American Hospital Association, "Fast Facts on U.S. Hospitals, 2025." https://www.aha.org/statistics/fast-facts-us-hospitals
6. Centers for Medicare & Medicaid Services, National Health Expenditure data / Fact Sheet and Projections; AHA, "CMS: National health spending increased 7.5% in 2023" (2024). https://www.cms.gov/data-research/statistics-trends-and-reports/national-health-expenditure-data/nhe-fact-sheet
7. Becker's Hospital Review, "How HCA, Tenet, CHS and UHS stacked up in 2024" (2025). https://www.beckershospitalreview.com/finance/how-hca-tenet-chs-and-uhs-stacked-up-in-2024/
8. HCA Healthcare, Form 10-K (FY2025), SEC. https://www.sec.gov/cgi-bin/browse-edgar?action=getcompany&CIK=0000860730&type=10-K
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12. Universal Health Services, Form 10-K (FY2025), SEC. https://www.sec.gov/cgi-bin/browse-edgar?action=getcompany&CIK=0000352915&type=10-K
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17. Definitive Healthcare, "Understanding Hospital Payor Mixes Across the U.S." (2024). https://www.definitivehc.com/resources/healthcare-insights/breaking-down-us-hospital-payor-mixes
18. Centers for Medicare & Medicaid Services, "FY 2026 Hospital Inpatient Prospective Payment System (IPPS) Final Rule." https://www.cms.gov/medicare/payment/prospective-payment-systems/acute-inpatient-pps
19. Centers for Medicare & Medicaid Services, "Hospital Outpatient Prospective Payment System (OPPS)." https://www.cms.gov/medicare/payment/prospective-payment-systems/hospital-outpatient
20. Kaufman Hall, "National Hospital Flash Report" (2024–2026); Becker's, "Hospital operating margins to stay low in 2025: Moody's." https://www.kaufmanhall.com/insights/research-report/national-hospital-flash-report
21. Centers for Medicare & Medicaid Services, "Emergency Medical Treatment & Labor Act (EMTALA)." https://www.cms.gov/medicare/regulations-guidance/legislation/emergency-medical-treatment-labor-act
22. 340B Health / HRSA, "Criteria for Hospital Participation." https://www.340bhealth.org/members/340b-program/criteria-for-hospital-participation/
23. Centers for Medicare & Medicaid Services, "No Surprises Act — Overview of rules & fact sheets." https://www.cms.gov/nosurprises/policies-and-resources/overview-of-rules-fact-sheets
24. Centers for Medicare & Medicaid Services, "Hospital Conditions of Participation." https://www.cms.gov/medicare/health-safety-standards/conditions-coverage-participation/hospitals
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26. National Conference of State Legislatures, "Certificate of Need State Laws" (Jan. 2025). https://www.ncsl.org/health/certificate-of-need-state-laws
27. Centers for Medicare & Medicaid Services, "Hospital Price Transparency." https://www.cms.gov/priorities/key-initiatives/hospital-price-transparency
28. Federal Trade Commission, "FTC Sues to Block Novant Health's Acquisition of Two Hospitals from Community Health Systems" (2024); FTC, "Health Care Competition." https://www.ftc.gov/news-events/topics/competition-enforcement/health-care-competition
29. Washington Center for Equitable Growth, "Hospital consolidation matters"; KFF, "Understanding the Role of the FTC, DOJ, and States in Challenging Anticompetitive Practices of Hospitals." https://equitablegrowth.org/research-paper/hospital-consolidation-matters/
30. U.S. Census Bureau, "U.S. Population Projections" (2023). https://www.census.gov/newsroom/press-releases/2023/population-projections.html
31. Healthcare Dive, "CHS' losses widen in 2024" (2025). https://www.healthcaredive.com/news/chs-losses-widen-2024-earnings/740449/
32. Forbes, "Trump's Beautiful Bill Puts Hospitals At Risk Of Closing" (2026); Georgetown Center for Children and Families, "Rural Hospitals and Communities Feeling Impact of H.R. 1 Medicaid Cuts" (2026); Congressional Budget Office projections. https://ccf.georgetown.edu/2026/05/01/rural-hospitals-and-communities-feeling-impact-of-h-r-1-medicaid-cuts-rural-health-fund-falls-short/
33. Private Equity Stakeholder Project, "Steward Health Care's bankruptcy: one year later" (2025); The Washington Post, "Senate report: How private equity 'gutted' dozens of U.S. hospitals" (2024). https://pestakeholder.org/news/steward-health-cares-bankruptcy-one-year-later/
34. CBS News, "UnitedHealth says Change Healthcare cyberattack cost it $872 million" (2024); UnitedHealth Group Form 10-Q (FY2024). https://www.cbsnews.com/news/unitedhealth-cyberattack-change-healthcare-hack-ransomware/
35. Medical Properties Trust, annual report / investor materials (NYSE: MPW). https://www.medicalpropertiestrust.com/
36. Universal Health Realty Income Trust, results and portfolio overview (NYSE: UHT). https://universalhealthrealty.gcs-web.com/