What is a hospital EBITDA margin, and how should you read Anahp's figure?
A hospital EBITDA margin is the share of net revenue left as operating earnings before interest, income taxes, depreciation and amortization. In Portuguese the same measure is also called LAJIDA. By the usual convention, the margin is EBITDA divided by net revenue for the period.
The main public benchmark in Brazil is the Observatório Anahp (Anahp Observatory), Anahp's annual report built on its Hospital Indicators System. The 2026 edition brings 2025 data from 138 of the 194 member hospitals [1]. The figure is an average across hospitals that are mostly large and high-complexity. Use it as a trend benchmark, not as a target for every hospital. The Observatory pages reviewed do not spell out the EBITDA margin formula.
Two definitional details change the reading. First, Anahp's net revenue is gross revenue minus taxes on revenue and minus amounts denied and not received [1]. In other words, a denial that becomes a loss has already left both the numerator and the denominator. Second, Anahp's total expenses include depreciation and financial expenses [1], which sit outside EBITDA. That is why total expenses ÷ net revenue, 93% in 2025 [5], is not the complement of the EBITDA margin.
The margin is where revenue cycle KPIs turn into earnings. The guide Revenue cycle KPIs gives the formulas for denials, collection time and recovery that feed this analysis.
Anahp hospitals' margin fell to the lowest point in the series
The average EBITDA margin of Anahp hospitals dropped 0.63 percentage point in 2025, to 11.05% [1]. It is the lowest value in the annual series published in the 2025 and 2026 Observatories, which starts in 2021.
See the numbers as a table
| Year | EBITDA margin (%) |
|---|---|
| 2021 | 11.72 |
| 2022 | 11.26 |
| 2023 | 11.89 |
| 2024 | 11.68 |
| 2025 | 11.05 |
| KPI (Anahp hospital average) | 2022 | 2023 | 2024 | 2025 | Source |
|---|---|---|---|---|---|
| EBITDA margin | 11.26% | 11.89% | 11.68% | 11.05% | [1] |
| Total expenses ÷ net revenue | 94% | 95% | 93% | 93% | [5] |
| Net revenue per patient-day (BRL, nominal) | 6,136.85 | 6,529.40 | 6,590.74 | 7,042.58 | [1] |
| Total expenses per patient-day (BRL, nominal) | 5,818.99 | 5,476.89 | 5,590.03 | 6,462.31 | [1] |
| Accepted denials (% of gross health plan revenue) | 0.78%* | 1.17% | 1.96% | 1.72% | [1] |
| Average collection period (days) | 73.51 | 76.38 | 69.91 | 77.35 | [1] |
* In 2022, the accepted-denial denominator was total net revenue; since 2023 it has been gross health plan revenue [1].
The reason for the decline lies in the balance between revenue and expenses. In 2025, net revenue per patient-day grew 6.86% and total expenses per patient-day grew 15.60%; adjusted for inflation by Brazil's consumer price index (IPCA), the changes were 2.49% and 10.88% [1]. Per hospital discharge, net revenue fell 1.51% and expenses rose 2.51% [1].
The 2026 quarters point the same way. In Q1, the margin was 9.45%, against 9.75% a year earlier [3]. In Q2, it was 10.60%, against 14.03% (2023), 12.51% (2024) and 11.69% (2025) in the same quarter [4]. Two caveats apply. Anahp's membership grew from 120 hospitals in 2023 to 203 in 2026, which Anahp itself says affects the figures [4]. And the patient-day concept changed in 2026, so 2026 per-patient-day values are not comparable with earlier years [4].
Where does the revenue cycle enter the results?
The revenue cycle enters the results through two doors: permanent loss, which cuts net revenue and EBITDA, and delay, which ties up working capital and creates financial expense below EBITDA. Separating the two avoids treating initial denials as a margin loss, or the collection period as if it cost nothing.
| Revenue cycle KPI | Anahp benchmark (2025) | Where it shows up | Effect on EBITDA | Effect on cash |
|---|---|---|---|---|
| Accepted denials | 1.72% of gross health plan revenue [1] | Net revenue (deduction) | Cuts it almost one-for-one: the cost of care was already incurred | Money that never comes in |
| Settlement discounts | No published figure [5] | Revenue (deduction or discount granted, per accounting policy) | Cuts it, like accepted denials | Money that never comes in |
| Initial denials | 15.93% of receivables from health plans [1] | Receivables under negotiation | None while disputed; cuts it if accepted or provisioned | Money held for months |
| Average collection period | 77.35 days [1] | Receivables; financial expenses | No direct effect | Working capital tied up; interest sits below EBITDA |
| Allowance for losses | BRL 1.8 billion in 2024 (85 hospitals) [6] | Expense (provision), per accounting policy | Cuts it when booked as an operating expense | None when booked |
| Collection rate | 85.80% of billings over 5 years [1] | Summary of losses and delays | Indirect | Shows how much of what was billed became cash |
The table uses Anahp's definitions and does not mix denominators. Initial denials are measured over receivables from health plans; accepted denials, over gross health plan revenue [1]. Dividing one by the other, or adding them up, produces a meaningless number. The guide Initial, final and accepted denials explains each KPI.
Accepted denials take margin almost one-for-one
Accepted denials are the revenue cycle loss that weighs most on the margin, because they cut revenue without cutting cost. When the hospital accepts a denial on a supply, a daily rate or a physician fee, care has already been delivered: the team worked, the drug was used and the supplier will be paid. Revenue falls, and the expense stays.
The effect can be calculated with a simple formula:
Additional loss = increase in accepted denials (in points) × gross health plan revenue New EBITDA margin = (EBITDA − additional loss) ÷ (net revenue − additional loss)
Illustrative example (hypothetical figures, not a real hospital). A hospital has BRL 90 million in gross health plan revenue, BRL 100 million in net revenue and BRL 11 million in EBITDA, an 11% margin. If accepted denials rise by 1 percentage point, the additional loss is BRL 0.9 million. EBITDA falls to BRL 10.1 million and net revenue to BRL 99.1 million. The new margin is 10.19%: 1 point of accepted denials cost about 0.8 point of margin and 8.2% of EBITDA.
A change that looks small in the denial rate equals almost a tenth of operating earnings. At Anahp hospitals, accepted denials moved 0.79 point between 2023 and 2024 (from 1.17% to 1.96%) [1]. Anahp also notes that, beyond accepted denials, hospitals accept discounts to close settlements and get invoices paid [5]. Those discounts have the same effect on the margin and usually stay outside the denial rate. To measure the real loss, add both on the dashboard, each with its stated denominator.
What does the collection period cost if it does not show up in EBITDA?
The collection period costs interest and opportunity, but that cost shows up below EBITDA, in financial expenses and net income. That is why a hospital can have a stable EBITDA margin and still lose cash and profit because of payment delays.
In 2025, Anahp hospitals took an average of 77.35 days to get paid, counted from the invoice date, and 48.30 days to pay suppliers [1]. That is 29.05 days the hospital finances with its own cash or with credit. Financial expenses, which include interest on loans, were 3.77% of total expenses in 2025, up from 3.17% in 2024 [1]. In Anahp's Financial Maturity Survey, with 31 responding hospitals, the longer average collection period and the higher Selic rate (Brazil's benchmark interest rate) appear as the main pressure on cash flow [7].
Additional capital tied up = health plan revenue per day × extra days of collection Annual cost = additional capital tied up × annual borrowing rate
Illustrative example (same hypothetical hospital). With BRL 90 million a year in health plan revenue, the hospital bills about BRL 246.6 thousand a day to health plans. If the average collection period rises by 7.44 days, as it did for the Anahp average between 2024 and 2025 (from 69.91 to 77.35 days) [1], another BRL 1.83 million is tied up. Financed at Brazil's average corporate working-capital rate for August 2026, 22.89% a year [8], that amount costs about BRL 420 thousand a year. It equals 0.42% of net revenue, and it comes out of net income, not EBITDA.
Each hospital's rate depends on its credit. The guide Cost of payer delays runs the full calculation, and the guide Hospital working capital covers ways to finance the gap.
Initial denials hit cash before they hit the margin
Initial denials do not cut the margin in the month they are applied, but they hold the money for as long as the dispute lasts. At Anahp hospitals, they were 15.93% of receivables from health plans in 2025, against accepted denials of 1.72% of gross health plan revenue [1]. Because the denominators differ, the gap between the two numbers is not a reversal rate. It indicates that much of what is denied at first does not hold up in the end, but stays held up along the way.
In a survey of 85 member hospitals, Anahp estimated BRL 5.8 billion in denials held up in 2024 and BRL 1.8 billion in allowance for doubtful accounts, against BRL 1.4 billion in 2023 [6]. The allowance is the point where delay starts to become a loss in earnings: when a claim ages without resolution, the hospital's accounting policy calls for recognizing the probable loss. Anahp's collection rate, which compares what was received with what was billed to health plans over five years, fell from 88.61% in 2024 to 85.80% in 2025 [1].
One method caveat applies. In 2026, Anahp changed the denominator of the managerial initial-denial rate from receivables to amounts received from health plans in the month [4]. The 2026 figures are not comparable with those for 2023 to 2025.
How do you link revenue cycle KPIs to the margin on a dashboard?
The most direct way is a monthly bridge from gross health plan revenue to EBITDA, with one line for each revenue cycle loss, broken down by health plan.
In practice, the bridge has five lines beyond taxes: accepted denials, settlement discounts, allowance for losses (when booked as an operating expense), unbilled accounts at month-end and financial expense attributable to the collection period. The first three affect EBITDA. The last two affect cash and net income. Each line needs an owner: billing and denial appeals for the first two, the controller for the third and fifth, billing for the fourth.
Three practices keep the bridge reliable:
- Service date: a denial accepted in October may relate to an April claim. Record both dates so the loss is not assigned to the wrong month.
- Stated denominator: every rate on the dashboard should say what it is calculated over, as Anahp does.
- Careful comparison: the Anahp average reflects high-complexity hospitals, with a sample that changed from year to year [4]. Compare trends, not absolute numbers.
The guide Hospital accounts receivable explains allowances and write-offs, and the guide Hospital days to payment details how to calculate the collection period.
What we see in operations
At Accrua, we connect the revenue cycle to the bottom line through the two doors this guide describes. Accepted denials come out of net revenue and cut margin. Initial denials and payment time hit cash first, through working capital and financial expenses.
When we read a hospital's history, we build that view by health plan: how much was denied, how much was overturned, how long it took and how much ended up as accepted denials or settlement discounts. Accrua OS reconciles each remittance statement with the claim submitted, so every number on the dashboard has the source claim behind it.
On margin, the work is at the source: checking the whole claim before submission and appealing with evidence. On cash, Receita Garantida puts the value of eligible production into the hospital's account when it needs it, and Accrua takes on the risk of eligible denials. The platform, the managed operation and Receita Garantida can be contracted separately.
Where to start
- Calculate the hospital's EBITDA margin with Anahp's net revenue definition (gross revenue minus taxes and denials not received) so you can compare it with the benchmark.
- Separate accepted denials and settlement discounts as their own revenue lines, broken down by health plan and by service month.
- Build the monthly bridge from gross health plan revenue to EBITDA and, below it, the financial expense attributable to the collection period.
- Calculate the cost of each day of collection with your own borrowing rate and take that number to health plan negotiations.
- Review the dashboard every month with billing, the controller and leadership, comparing the trend with Anahp's Observatory and quarterly reports.