The hospital industry has been struggling for years with razor-thin margins and falling reimbursement. But with Wall Street having a meltdown, too, denying hospitals much-needed capital and credit, this year was something of a capper.

To try to deal, hospital CFOs took some drastic steps. The Wall Street meltdown forced hospitals to restructure their debt whenever they were allowed, such as in California [1] and Massachusetts [2]. Others, however, were simply left holding the bag when their bond rates shot up into the double-digits due to financial market turmoil. Some hospitals were able to refinance their bonds based on the strength of their own credit [3], but some were just out of luck when bond insurers like Ambac stumbled themselves.

So how have hospitals survived? In some cases, hospitals have begun asking for payment up front [4] to reduce bad debt. Some have announced large restructuring plans, or put off multi-million dollar capital projects. Meanwhile, many hospitals had to lay off employees to try to make ends meet, leading to a record number of mass layoffs [5] this year. The truth is, though, that it seems few have escaped unscathed. It's been something of a bloodbath.

Unfortunately, next year may not look much better. The troubled housing market may increase bad debt [6], as consumers continue to battle sky-high mortgage rates and unemployment. Meanwhile, insurers are struggling too [7], which doesn't bode well for wresting good rates out of them at contract time. Let's keep our fingers crossed.