Moody’s Investors Service placed Cleveland-based MetroHealth System on watch list for potential downgrade due to a decline in financial performance through the first nine months of fiscal 2011. The credit is rated A2.

The performance in 2011 so far is a “major departure” from 2010 projections, analysts said.

The system is owned by Cuyahoga County, the most populous and wealthiest county in Ohio. As Cuyahoga’s safety-net hospital, it derives nearly 50% of its patient revenue from Medicaid or self-pay patients and relies heavily on the county and state for financing.

MetroHealth has about $270 million of outstanding debt.

Standard & Poor’s rates the system BBB-plus.

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