Fitch Ratings has revised its outlook to negative from stable on the A-minus rating of Missouri's Bethesda Health Group Inc. due to balance-sheet strains from low occupancy levels and flat revenue growth that heightens concerns over its aggressive debt profile.

The rating action applies to $75 million of BHG's variable-rate demand health facilities revenue bonds issued in 2009. The bonds carry a letter of credit from U.S. Bank. Put risk is heightened by the December expiration of the LOC, and cash to puttable debt is 91%. Bethesda has begun discussions with potential credit providers, according to Fitch.

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