Great. Well, good morning, everyone. I'm Craig Hettenbach. I cover the healthcare technology and provider space for Morgan Stanley. Very pleased to have with us Ardent Health this morning. So, CEO Marty Bonick and CFO Alfred Lumsdaine. So, welcome.
Thanks. Thanks for having us.
Thank you.
Before we kick off, I do have to remind investors for disclosures. You can find them at the Morgan Stanley website, www.morganstanley.com/researchdisclosures. So with that, and on the heels of your recent IPO, I think for investors that are new to the name, Marty, maybe we can just start with a big picture, intro to Ardent Health.
Yeah. Thanks, Craig. It's great to be here. This is our first conference as a public company, so this is a great way to sort of kick off our our new existence. But, Ardent, for for those that are newer to the story, is a hospital health services company. We cover eight markets in the eight markets across six states, highly concentrated in the South Central, Texas, Oklahoma, New Mexico being our largest markets. And we've got 30 hospitals, over 200 sites of care, through a combination of clinics, ASCs, urgent cares, and and the like, and over seventeen hundred providers, which our clinics are an important part of our story.
We we service sort of mid-markets, middle middle-sized urban markets, where we can have a multiple hospital footprint, with a hub-and-spoke strategy, and we go really deep in those markets. The markets that we're in are sort of high growth. They're growing three times faster than the U.S. average, and, you know, we've seen the benefits of that play out in terms of utilization and volumes.
Got it. And what would you say differentiates, you know, Ardent from some of your public and private competitors?
Yeah, from a differentiation perspective, we have grown our company through a series of joint venture relationships, and we've got partners with academics and nonprofits across multiple markets, and we see that as an expansion opportunity. These partnerships allow us to go into a new territory, partner with an academic. Most recently, our our latest acquisition was a group of hospitals in East Texas, a very fast-growing MSA, but we took on a challenged group of hospitals. This was back in 2018 , partnered with the University of Texas, and UT Health East Texas now is is, you know, a predominant brand across East Texas.
We've got a very dense footprint in that market, and you know, that's an opportunity for us to take advantage of what the university can bring, the name, reputation, their brand, their ability to recruit specialists, and subspecialists. In East Texas, most recently, we opened up an ECMO program, which is a advanced cardiac life-saving procedure, and we were able, because of the strength of the university and people wanting to have those academic affiliations and appointments, to recruit in subspecialists to be able to provide that service. We're the only hospital in all of East Texas to offer that.
And, you know, previously, those patients did not have any availability for ECMO services in East Texas, and so now, we're able to be that regional destination center, and so just one of the examples of that partnership. But the clinical recruiting, nurse recruiting and training programs, there's a lot of benefits that happen as a result of partnerships. And for the academic partner, we're able to help them expand their brand across the state and really bring the strength of our management team and our ability to manage community hospitals, which is very different than managing an academic center.
Great. And can you touch briefly just on your relationship with your largest investor, EGI, and then also Ventas?
Yeah. EGI has been a great investor. They have a very long-term philosophy. EGI and Ventas purchased the company from Welsh Carson back in 2015 , and, you know, obviously, they've been involved for nine years. They're our largest shareholder, and, you know, we expect a long relationship with them. But most importantly, they've always had a long-term vision. They focus on sustainability. So when you look at our balance sheet and our leverage profile, you know, we are, you know, very appropriately levered for a company of our size and expect that to continue to improve, as our guidance has suggested, and they're really focused on long-term sustainable relationships, you know, sort of slow and steady growth. As you look at the trajectory of the company since they've owned it, it's had a nice growth pathway, and, you know, we're looking forward to continuing that.
Great. It's a few months since you came public, but just curious, kind of get feedback in terms of within the company, at the board, you know, how how you thought IPO process went, where we stand today?
Yeah, it's really an opportunity to just really thank our team. I mean, we wouldn't be here without the hard work of everybody across the company. You know, what we do is people caring for people every day in our hospitals and our clinics across, you know, the country, but our management team, you know, really you know deserves a lot of credit. As you all know, going through an IPO process is not easy. We appreciate our partners, you know, our banks that helped us to to sort of navigate that that pathway, which is long and arduous. But, we're excited to be here on the other side of it, and excited to see, you know, the investor interest in what we're doing, and most importantly, the care we're providing and our ability to take that care and grow that across the country.
Got it.
We're excited about the access to capital that it brings as we think about executing on our growth strategy. It just, you know, we find ourselves at a point in time, you know, coming out of the pandemic, a period of time where there wasn't a lot of M&A activity, and now we really see a much more active pipeline, and we think, you know, by being public, we're we're in a position to, you know, execute on that strategy more effectively.
Excellent. When you talk about the road to get here, and it takes a lot, the important thing is once you get there is first quarterly report, and it was a strong one. To get your thoughts in terms of what you thought were the key highlights for Q2.
Sure. You know, Q2 is very much, you know, consistent with what our overall expectations. You know, we've all seen, you know, good return to good, robust volumes across the industry. We think of it internally as really a return to normal. And so that that was really the primary impetus of, you know, good, good strong volume growth. And really an abatement of some of the inflationary pressures that we've seen through the pandemic. Certainly, you know, contract labor has come much more back into line with historical levels. I think as a percent of salaries and wages, we were down to 4.3%, from 5.7% a year ago. And, you know, we kind of think we're getting to that new normal level.
While that's still elevated above where we started the pandemic, it's sort of at a level and at an hourly rate that we think is sustainable, and we see that in our nurse wage rates as well, you know, where those extreme market adjustments have abated back to, you know, what I'll call normal COLA-type levels, where we were prior to the pandemic. And that's also a dynamic that's influenced by our overall nurse turnover, clinical turnover below 15%, actually below 14% in the most recent quarter, which is even below pre-pandemic levels.
That's great. And on the call, you introduced kind of the long-term targets of how you're thinking about the business, kind of mid-high single-digit revenue growth, low double digits to mid double-digit EBITDA growth, and kind of mid-teens EBITDA margin. Can we just spend some time just talking through those building blocks and how you see the business evolving there?
Sure. There's a couple dynamics at play. Marty's already touched on the strength of our markets in terms of overall population and wage growth as being above U.S. averages over 3% on average, which is a driver. You know, as we think about the growth algorithm, sort of that rising tide of population growth is a built-in tailwind in the markets that we're in. And then we think about, you know, commercial rates. Clearly, the last 24 months, we've been able to get above historical rates to help offset some of the inflationary pressures that we saw through the pandemic, and that's been a tailwind as well. Well I'm sure over time, that goes back to a more normalized, you know, again, call it 3%, you know, 3%- 4% type increases.
But you compound that to our population growth in our markets, as well as our efforts to grow our ambulatory access points in our markets. Historically, we think there is a big opportunity to create more access points, to create more sites of care, and to capture the patients where they want to be seen and built grow our market share inside of our markets. We think that's been an under-penetrated opportunity. So from a top-line perspective, we think that's the algorithm to mid to upper single digits. And then when we think about our EBITDA growth, a couple dynamics at play there. One, historically, the states we're in have been underrepresented from states with DPP programs. I think before the Oklahoma program went live this April, only about half of our beds were in states with DPP programs.
Once New Mexico's program gets approved, which has been submitted to CMS, will be, like, 90% of our beds in states with DPP programs. And that's... You know, we'll call that a one-time adjustment in our margin profile, but it gets us much more in line with where our peers operate from a from a margin perspective. And then lastly, we think we have a we still have opportunity. We've spent the last several years creating an operating platform. Ardent had grown through acquisition and hadn't done a full integration of those acquisitions until the last, call it three to four years, and we spent the last three to four years creating that operating platform. We still have leverage to get out of that, not fully scaled today, but we think there's still margin opportunity over the coming, you know, call it three to five years, to to create more margin uplift there.
Got it. Alfred, maybe just building on on that in terms of, are there any specific operating initiatives or things that you would call out, that that should help margins over time?
Sure. One I'll point to is, we've had a big effort this year on our supply chain initiatives, and that is to create, you know, really, improve operating improvements across our, you know, all the blocking and tackling, inventory levels, obsolescence, physician preference items. And we've seen that already in our supply chain, as a percent of our revenues down year over year, over 100 basis points, and we still think we're not complete with those initiatives yet. That'll run into 2025, so we think there's still opportunity inside of supply chain, as one example.
Got it. Marty, I'd love to talk about just some current macro conditions. There's been a nice, strong rebound. I think the investor debate is just durability on these trends. And so what are you seeing in your markets from utilization perspective, and anything you'd call out in terms of acuity?
Yeah, I I think, you know, there's there's a lot of conversation about this and, you know, coming out of the pandemic, obviously, the last few years have been anything but normal. You know, you've always got seasonal variation, but the highs and the lows were accentuated during different periods of the COVID pandemic. You know, we feel that we are back to a you know pre-pandemic sort of normal volume trajectory. Again, our markets are growing faster than the U.S. average, and we were seeing positive growth rates before the pandemic, and, you know, we we see ourselves getting back on that track, you know, firing across all cylinders. You know, this year we've been benefited a little bit by the Two- Midnight Rule and payers coming into compliance with that.
And so, you know, that's been an increase in our admissions year over year. But, you know, we're absent that, which tend to be lower case lower acuity, everything else has been sort of back to what we would consider a, you know, sort of pre-pandemic normal level.
Got it. And and you touched on before, Alfred, in terms of just kind of rates coming up a bit. How how are you thinking about where things stand today? Any insights you can give in terms of expectations as you kind of leg into next year?
Yeah, you know, it's been, like I say, a couple years of really negotiating hard at the table in terms of getting adjustments that are more reflective of the type of inflationary environment that we were operating in, with nurse wages, contract labor, hospital-based providers, and, you know, the significant acceleration of those costs and trying to get some offset to that. And we, we've been successful, you know, in getting above historical average increases, you know, call it over the last 24 months. We haven't really seen a trend down yet. However, you know, I think we all hear the same things in terms of, and and see, you know, where the MLRs are landing with payers, and I, you know, I'm hearing commentary that there's...
and expecting there to be more pushback on the types of increases that we've been able to get over the last 24 months. Again, we're at the negotiating table every day, and, you know, we still believe we haven't fully, you know, been received the types of rates to offset those inflationary pressures that we felt historically. And we also understand, you know, we're likely going into a more difficult negotiating environment in the upcoming 12 months.
Got it. So I'd love to talk about some kind of bigger picture trends for the industry. Like you said, Marty, so much changed kinda through COVID and coming out of it. What are you seeing in terms of patients, how they're accessing care? I know you're building out ambulatory. How are you positioning for, you know, the business as we go forward?
Yeah, I mean, obviously, coming out of the pandemic, you had a period of time where it was difficult for patients to access care just because of either the number of COVID patients in the hospital, and/or, you know, some of the fear of of going in for elective procedures and such. And that really opened up, you know, something that was already there in terms of the ambulatory environment, but, you know, I think it really, you know, poured gasoline on that opportunity. And so you've seen this proliferation and a shift from inpatient to outpatient and and some lower acuity surgeries, you know, but just the accessibility. And so, you know, for us, we we did a lot of M&A, you know, sort of in the late teens years, and, you know, we're really focusing on integrating that.
We have a tremendous amount of opportunity to expand care in our markets, whether that's urgent care, access points, freestanding ER, imaging centers, ASCs, and perhaps even micro-hospitals in some cases, in some of our high-growth markets. You know, they've become an "and" strategy for us versus an "or," so we're gonna continue to focus on high acuity service line growth and making sure we can take care of those really complex needs that patients have inside of our hospitals, but at the same time, we wanna make sure from a value-based care perspective, that we've got easily accessible, affordable, you know, options for patients to receive care in the most appropriate setting for their condition.
And so, you know, for us, this is really a growth strategy on both sides that we see to take advantage of how how the populations have shifted. You know, telehealth and virtual health has been another thing that you know was around before the pandemic, but you know we were we were seeing maybe 1,000 patients a month you know pre-pandemic. That went to about 60,000 patients a month you know the first couple of months as clinics shut down and people were looking for options, so 60x growth is really nice, but obviously wasn't sustainable, and you've seen those numbers come down.
But we're still in, you know, sort of the low teens, you know, what we've seen, and that's a growing business now that people see that I don't have to necessarily get my car in and go wait in line in an office or an urgent care for something simple when I when I need that care. That's that's an option for them that they have. And so we see that as an integrated part of our offering of meeting the patients where they're at, you know, creating access points that are gonna help them, and creating sticky relationships with them.
You know, we want to have relationships with patients that span the gamut, and I think, you know, the focus that we are doing is building that integrated health system that allows us to provide that longitudinal care in whatever the appropriate setting is, versus some some of our, you know, competitive companies and some of the quote, unquote, "disruptors" in the industry that have come in and and sort of highlighted the opportunity, but can't connect the dots. And so, you know, patients don't tend to live in point solution worlds, and so we want to be able to provide the primary care, the specialty care, the virtual care, the facility care that they need, so we can care for them across their life and their continuum of care.
Got it. And maybe just building on this, and you've been in the industry for decades, right? And so, you've seen a lot of change, as the space has evolved. And what's important in terms of for you to make sure that you're positioning Ardent to capture these changes in terms of patients, how they're getting care, and building out the overall strategy from an execution standpoint?
Yeah. For us, it's about, you know, truly, you've heard about consumer-focused care for decades. We've been talking about it, but I think, you know, this is really the inflection point where we can deliver on it. You know, the technology is evolving. The affordability is is is, you know, getting in more in line with things that we need to be looking at. And, you know, if we don't do it, you know, you see people coming in and showing that it can be done. And so for us, it's really, you know, connecting that dot from a consumer strategy and really putting them at the center of the universe. You know, as I said, I've been in this industry for 25+ years, and it was always: We have built it, these big, large hospitals and facilities, and you must come.
And patients still do come, and they're gonna need that. Always need that higher level of access to care, but you know, you don't necessarily need to come to, you know, it's kind of the equivalent of the big box shopping mall if you can drive up to the strip mall that you can go directly to the store you want. Same thing. People want the same thing in healthcare that they want in their day-to-day lives. They want access, they want convenience, they want it now. You know, we've focused a lot on the consumer engagement side from a technology perspective and making it easier for them to schedule appointments to, you know, talk with their doctors, to pay their bills.
You know, everything that you can do from your phone, you know, in your normal life, people want that in healthcare. And historically, this industry just has not provided that, but we've put a lot of money and effort into that. We spent $250 million putting Epic in, which Epic is the KLAS-leading electronic health record and really clinical operating system backbone for our company. You know, we did that as a private company, and we see that's paying dividends now and will continue to pay dividends as they continue to evolve their ability to help us engage and stay engaged with our patients in meeting their care needs, often before that they even know what they need. And so, being able to connect the dots and create that seamless consumer experience is is where a big focus of ours is, and how do we touch more people in each of our communities?
Got it. Just building on that, you mentioned there's disruptors in the space. You have large, diversified healthcare companies, you have tech companies getting in. You know, how is Ardent positioned relative to what's this changing environment? What are some of the things you're best leveraging today? What are some things you wanna be kind of on the front foot, if you will, to make sure you stay ahead?
Yeah, no, I mean, we we see technology as an enabler for us, as well as, you know, a partner. We're not gonna be able to do everything ourselves, and we've got some really great partners that are helping us to sort of pilot, you know, what I call sort of the next generation of care delivery. You know, we we have the same challenges and pain points that the industry has. You know, you've got physician burnout issues, you've got, you know, nurse recruitment, retention issues. There was a lot of, you know, people that left the field or retired early during COVID, and, you know, we're still, you know, grappling with the aftereffects of that, and so how do we make it easier for our caregivers to deliver care at the bedside?
How do we make it safer and more effective for our patients to receive care in our facilities and access our clinics and services? So you know, things that we've invested in. We've got a partnership with BioIntelliSense, and they make. I usually have one with me, but something about the size of your watch. That's a little patch that sits on your chest, and it replaces the EKG box that we typically put around a patient's neck, and the blood pressure cuff and the pulse oximeter. You know, we put you in a hospital bed, and you're connected to all these wires. It's uncomfortable. You turn, they're alarming, they rub off. This little device is just a small wireless patch that's communicating and electronically transmitting your vitals.
So it's taking that care burden and taking some of the burden of collecting the vitals away from our caregivers, but they're also collecting that information once a minute now versus, you know, four to six times a day, which is what typically happens in a med-surg environment. So so not only are we making it easier for our nurses to do their jobs, we're giving them better information. So if a patient is deteriorating, you know, during their stay, we're gonna notice that quicker, and that's gonna prevent, you know, somebody perhaps having to crash and go to the ICU and end up in the hospital for a longer period of time. We can medically intervene much more quickly 'cause we're giving nurses information they can act upon.
We've also invested in virtual nursing services, where we can bring nurses in remotely and really change the dynamics of the care team that we offer, and so this is a little bit of back to the future for those like me that have been around this industry for a long time. We used to have LPNs, RNs, nurse techs, and aides, and it became much more of an RN-driven model, where there's not enough nurses to go around, so how do we augment the care model? It's not about replacing nurses; it's about bringing the right nurses and the right support to the patient to care for them.
So now we can zoom nurses into their room, you know, through the TV, and they can help with the admission process. They can help with discharge instructions, medication reconciliation, and these are all really important tasks that our nurses have to do, but they're time-consuming, and you don't wanna rush the patients. You wanna get a good history on their admission, so you're treating them effectively in a good medication list. Well, these virtual nurses can now zoom in and spend the time with those patients, and and we're seeing patient satisfaction go up. We're seeing nurse satisfaction going up. You know, early results, you know, we expect that turnover in our nursing units to come down because we're bringing more support.
But we're also able to augment with LPNs and and aides at the bedside to provide the right level of care and make sure we've got the right number of patients or the right number of caregivers, you know, roaming the halls and helping our patients where that's needed. And so a lot of investments in technology, not for the cool innovation side of it, but really for the practicality of addressing the pain points that we see in the industry and what our nurses and doctors are telling us.
Got it. Alfred, I wanted to go back to just... You commented briefly on kind of Oklahoma and New Mexico, and that puts you on kind of more of an even setting here. It it has been, I think, an investor debate around these programs, and particularly, we have an election coming up. And so can you just touch bigger picture for the industry, just the importance of these programs, how they work, and just the sustainability?
Sure. You know, well, I'll speak from Ardent's perspective. You know, we think these are very important programs. I believe with New Mexico's program, when that goes live, it'll be the 44th state to have a DPP. So it is really organic to how Medicaid programs are paid for and reimbursed really all across the country today. You know, it is important to note that the programs were started under a Republican administration, have continued under a Democratic you know administration. I know there's always a lot of conversations in an election year, but, you know, we think the most important thing is that, you know, appropriate funding is being provided to care for Medicaid patients.
And when I think about, you know well, you know Ardent has had a good year and a good quarter, you know, we still are in an industry that is struggling with something like, you know, 30% of all hospitals losing money. And, you know, these programs really have been a lifeline to, you know, again, to the cost of care, across the country. So, you know, our perspective is that it's important, you know, for patient care and that these are very durable programs. You know, CMS has put out guidelines, beginning, I believe, in 2028, around, you know, to bring some conformity to how these programs are structured, because there is a lot of, variation across the country. And, you know, I think conformity, would likely be a blessing, easier to administer.
But, yeah, our perspective, again, is very much that the, you know, for us, it just allows us to, you know, invest in those markets and communities.
Got it. And you mentioned New Mexico would get you to kind of 90%. You still have kind of Kansas and Idaho out there. How do you think about that in terms of handicapping, timing, or-?
Yeah, I, you know, 'cause as I mentioned, you know, with 44 states with a program, I think we are at a tipping point. This isn't, you know, my own perspective, it's likely a when, not an if. You know, I'd be loath to kinda predict timing. There is nuance to how these programs get implemented. You need a managed Medicaid structure, and that can take time. It certainly did in the in the state of Oklahoma to first stand up a managed Medicaid program before they put in the DPP program. So, but, you know, I think our perspective is that, you know, we we think over time, you know, I would expect all states will have a program.
Got it. Marty, I wanted to come back to what you mentioned the JV and partnership strategy, which which is unique, and and more broadly, M&A was put on hold. Alfred, you talked about the pipeline's robust now. So how should investors think about kind of the opportunity set out there and the potential for inorganic growth as we go forward?
Yeah, I mean, it for us, you know, our last acquisition was 2018. It was a sizable acquisition, and as the company was digesting that, you know, COVID hit. And so, you know, our caregivers were taking care of COVID patients, and then Alfred and I entered the company about that time and really focused on getting this company ready to scale to that, like, next level of growth, which, you know, a lot of hard work was done behind the scenes to make that happen. Finishing our installation of Epic, really centralizing and standardizing our management teams and functions in terms of how do we operate to take advantage of the size and scale that we've become. And we believe we're at that point now where the M&A the window has opened back up.
Our balance sheet's in a good spot. You know, we, we've got the appropriate leverage to be able to, to take on strategic M&A, you know, of, the right size for us. That we're not gonna do something that's that's too big, that's gonna risk that profile, but we see the opportunities out there. You know, during the early years of COVID, there wasn't a lot of M&A happening really across the industry, period. And and we're starting to see those windows open up. Alfred, you know, stated that you still have about 30% or so of the hospitals that are losing money. And again, there's not every hospital is going to be a target for us. You know, we've we've carefully talked about, you know, these mid-size urban markets that we're very focused on.
There's a lot of them out there. We've quantified that, you know, in terms of what we see as the opportunity universe, and we're gonna be very selective inside of that window. You know, we want to to go into a market where we can get a sizable foothold of of facilities, hospitals, and then continue to expand our strategy through the physician clinic expansion, through the ambulatory expansion, and, you know, make a sizable impact. You know, we're not looking to grow dots on a map, but we believe that that's gonna offer a lot of opportunities for us to look at M&A. Our pipeline is as robust as it's been since Alfred and I have been here. We've got a number of conversations.
We do have ongoing conversations with some of our current partners about expanding in the states that we're in, as opportunities come up, as well as some some new academic partners that have taken note of the model that we have and the success that we've had in Texas, and Kansas, and New Mexico, with our our JV partners, and see that as an opportunity for them to grow their footprint, and so we're excited about the pipeline. Don't have anything to talk about today, but but you know, given the conversations, you know, we would expect to see you know some M&A in the in the not-so-distant future.
Got it. And and you mentioned a lot of hospitals are hurting today in terms of losing money, and so how does that enter the equation in terms of as you view the opportunity set, in terms of a health system that maybe financially isn't sound, but there's things that you can do operationally or to help that? How do you, how do you..
Yeah, and that's where I think that, you know, it's not that we would exclusively enter, you know, a new opportunity through a JV partner, but we do see that as a strategic advantage that we have. You know, why is that particular asset struggling? Is it is it under management or underperformance? Is it lack of recruitment? Is it its position in the market? Is it its perception in the market? You know, understanding the dynamics of what ails that system, you know, is what leads us to say, "Okay, where where can we really help?" But we believe that academic partnership and, you know, go back to the Texas example, you know, coming into that market, you know, all of the hospitals were, you know, it was significantly negative EBITDA.
By the end of the first year, we had brought that to cash flow positive. By the second year, you know, improving margins, and they've continued to improve since since that acquisition. But that was really the strength of, you know, a strong partner that had a brand image. You know, Texas, everybody loves the University of Texas, I guess, unless you're an Aggie. You know, and so people have really gotten behind that brand. But but as importantly, we have to deliver on quality, we have to deliver on service and, and you know, bringing new specialists to town, offering offering new and expanded clinical services, bringing services that were formerly only available in Dallas, or Houston, or San Antonio to East Texas.
You know, those are the things that that partnership allows us to do, and we're able to help, you know, bring our management expertise, bring our Epic platform, you know, and our ability to operate against that. But having a you know an academic partner that can bring some of those intangible factors, you know, like that physician recruitment, and the brand and perception, reputation, are all important ingredients that we think will allow us to go into a market that may have been struggling and and bring the solutions to what what will help that situation turn around.
Got it. I wanna talk about the mix of the business in the remaining minutes, also for investors. Open it up. If you have a question, we'll bring a mic around, but when I think about kind of 90% inpatient, 10% outpatient, how do you see that evolving over time? What are some of the key strategic initiatives from a mix perspective?
Yeah, and just for clarity, that you know, it it. The outpatient revenue is a higher percentage than the 10% sort of pure play you know outpatient facilities, but it just is indicative of the growth opportunity we have in our markets. It's not that the outpatient care doesn't exist, it's just where historically where our focus wasn't. But again, as we've improved our balance sheet and we've improved our operating performance, we've expanded and very carefully you know crafted the organizational structure to have you know co-presidents, one for the hospital side of the equation and one for the health services, the ambulatory, the physician clinics, the value-based care initiatives. We want to you know press accelerate press accelerator down on both of those.
We wanna continue to grow and strengthen our hospitals, but we wanna grow that outpatient performance, and and we see the opportunity to do that. You know, we've we've had historically, you know, you know sort of low 20% penetration, total inpatient share of the wallet in our markets, but historically, have had sort of low single-digit percentage exposure on the outpatient side. So it just shows the opportunity for us to grow, whether that's through de novo adds, because the growth of our markets are, you know, continuing to build just through the natural organic growth, or through M&A. As we, you know, have the right opportunities come about where we can see an accretive acquisition to go further, faster on accelerating that outpatient strategy, we're gonna look at both of those opportunities.
Great. Are there any questions in the audience? You can... As we wait for that, oh, there's one there. Just they'll bring a mic.
You mentioned your participation in valuation. Can you just- Oh, super. Thank you. So just as you're looking at the market landscape and, you know, your payer mix, what aspects of value or risk arrangements are you leaning in to pursue, and how do they fit with your overall model and the delivery capacity that you have set up?
Yeah, great, great question. You know, we've got 80+ different value-based arrangements in our current managed care contracting landscape, and about, call it about 225,000 lives that we cover through a combination of commercial managed Medicare, managed Medicaid plans, and you know, we're very very focused on those. You know, that's part of the reason we have such a robust infrastructure on our physician primary care network, you know, growing specialty network, is to be able to service those those patients and grow. You know, from a continuum, I mean , if I asked everybody in this room to explain value-based care or their definition, we'd get, you know, 50 different answers, but you know, you've got from fee-for-service all the way to full risk capitation. We're we're kind of in the middle.
We're we're focusing on shared savings plans, MSSP programs, and, you know, approaching sort of that shared risk. But, you know, we're we're carefully, you know, wading into those waters. And, you know, what we're seeing through our ACO partnerships that we have in each of our different markets, is that we are achieving those shared savings. You know, not life-changing economics at the current, you know, state, but we do see the opportunity to grow that shared savings, as we continue to just improve our processes, you know, continue to deploy our technology, and, you know, make sure that we're giving information to the physicians and have that right specialty network to actually manage that population health.
We see that as a as a future growth lever that we have that's, you know, still in its early stages. But we are staying away from sort of that full risk capitation. We don't wanna put the company at risk. You know, again, given the mid-size markets, you wanna make sure you've got an actuarial base that can support that, and you've got a network that can manage that effectively. And you know, we're we're not going to to push that agenda into a point where it's gonna put the company financials at risk, but where we can see that pathway and trajectory, where we're seeing those improved clinical outcomes that are driving contractual value back to the system, you know, we're gonna continue to expand in that area.
Great. I think that takes us to time. So Marty and Alfred, thank you so much for spending the morning with us.
Thanks for having us, Craig.
Thank you.
Appreciate it.