Moody's Investors Service today reported a sharp rise in bond rating downgrades for not-for-profit hospitals in fourth-quarter 2008, citing the negative effects of a rapidly weakening economy, restricted access to capital, investment losses and the growing risks associated with variable rate debt. The credit rating agency downgraded 18 hospital bond ratings in October and November, while upgrading only one. "We expect there to be a heightened number of downgrades over the next year as virtually all rated health care credits are facing some degree of credit stress due to these factors," said Moody's Vice President Lisa Goldstein. Moody's reported softening hospital revenues caused by patients deferring elective procedures, growing competition for insured patients, and increased charity care and bad debt expense due to rising unemployment. Last week, Fitch Ratings revised its outlook on the U.S. not-for-profit hospital sector to negative from stable, citing similar factors.