Troubled Steward Health Care may have to close or sell its hospitals, several of which are in Massachusetts. But private equity firm Cerberus Capital Management is a big winner,

having gained $800 million after cashing out of Steward in 2021, columnist Larry Edelman writes.

This column is from Trendlines, my business newsletter that covers the forces shaping the economy in Boston and beyond.

It was a match born of voracity and desperation, as many private equity buyouts are. Cerberus Capital Management hit a home run with Steward Health Care. But Steward may be about to go down swinging.

Rewind: In 2010, Cerberus agreed to bail out Caritas Christi Health Care, a struggling network of six Catholic hospitals serving mainly poorer communities in cities including Boston, Brockton, Fall River, and Methuen.

The New York firm paid $246 million in cash, assumed more than $200 million in pension liabilities, and promised to invest $400 million in the company, which was rechristened Steward Health Care. When the deal was announced, a Cerberus executive told the Globe it was “a big win for the hardworking communities of Greater Boston.’’

Fast-forward: After a national expansion, Steward is on the ropes.

Last week, the Globe’s Jessica Bartlett broke the news that the company — now owned by a group of physician-managers — is having trouble paying rent and may have to sell or close hospitals.

But the deal was a big win for Cerberus. It cashed out of Steward in early 2021, quadrupling its money with an $800 million gain, according to Bloomberg.

The backstory: Cerberus bought Caritas Christi four years after a blockbuster hospital deal: the 2006 leveraged

buyout of HCA for $21 billion by Kohlberg Kravis & Roberts and Bain Capital of Boston.

The sheer size of the acquisition — and the involvement of two respected firms — supercharged a health care buyout binge that extended beyond hospitals to nursing homes, physician practices, and home health providers.

Cerberus jumps in: After taking a high-profile beating on its 2007 bet on Chrysler, Cerberus saw an opportunity to profit on a turnaround of the “St. Elsewhere”-esque Steward. The plan: Buy up other hospitals around the country, deploy new technology, improve efficiency, control costs, and bill Medicare and Medicaid as aggressively as possible.

It was a vision adeptly articulated by Dr. Ralph de la Torre, Caritas’s chief executive officer who remained in charge under Cerberus. But it was a tough slog for the cardiac surgeon. His expansion plans were thwarted, and Steward didn’t make any money until 2015, when a reduction in pension payments put it in the black.

The big breakthrough: The following year, Steward sold its hospital properties for $1.2 billion to Medical Properties Trust, a real estate investment trust that also paid $50 million for a 5 percent stake in the company.

Steward, which leased the properties back from Alabamabased MPT, earmarked the proceeds to buy more hospitals and pay down debt. It also returned Cerberus’s initial investment, though the firm held on to a controlling stake in the company.

In effect, de la Torre had landed a new financial backer, letting Cerberus off the hook.

“We look forward to expanding our relationship with Steward in the years ahead,” MPT chief executive Edward K. Aldag Jr. said at the time.

And MPT did just that in 2017, writing a $1.4 billion check and buying an additional $100 million of Steward equity. De la Torre used the money to buy IASIS Healthcare, a $2 billion purchase that gave Steward 18 hospitals in Arizona, Arkansas, Colorado, Louisiana, Texas, and Utah, making it the largest for-profit chain in the country.

The next year, de la Torre moved the company’s headquarters to Dallas, where taxes are lower and regulations lighter.

Minimal disclosure: As a private company, Steward isn’t required to make its financial statements public. Moreover, it has largely ignored Massachusetts requirements that it file detailed financial information on an annual basis.

But publicly traded MPT discloses some Steward financials because the chain is its largest tenant, accounting for about 20 percent of revenue. That’s how we know that Steward booked operating losses of $322 million in 2017 and $270 million in 2018.

Steward’s leaseback deal with MPT significantly boosted its expenses, but as Jessica Bartlett reported, the health system blames its dire financial straits on rising interest rates and labor costs, an increasing Medicaid population, and difficulty collecting bills. MPT has been hit hard by Steward’s woes. Its stock tumbled nearly 40 percent after it announced earlier this month that Steward was having trouble paying rent.

Moreover, COVID clobbered all hospitals. Despite receiving government pandemic aid and hundreds of millions of dollars in loans from MPT, Steward is strapped.

Good timing: Cerberus was out before the bedpan hit the fan.

In May 2020, it swapped its stake with Steward doctors in exchange for a note paying interest. Then, in January 2021, Steward borrowed $335 million from MPT to pay off the debt. Cerberus was free and clear.

Parting thought: It’s not the only time the firm — named after the three-headed dog that guards the gates of Hades in Greek mythology — scored big on a company that went bust.

It did well on its buyout of Mervyn’s by selling off the department store chain’s real estate before it went bankrupt. And it recouped its investment and then some at arms maker Remington by paying itself a dividend before the company went broke. Such strategies are common in private equity.

You see, when firms like Cerberus do business, it’s often “Heads I win, tails you lose.”