Of Ardent Health. We are hosting Marty Bonick, Chief Executive Officer, and Alfred Lumsdaine, Chief Financial Officer. We also have in the room Senior Vice President, Investor Relations, Dave Styblo. Welcome, guys. Thank you for joining us.
Good to be here, Ben.
Great. Maybe if you can kind of just open with a few words on your thoughts on the state of the world.
Yeah, it's certainly been an interesting time in healthcare, if you're following the news, of course. For those that are less familiar with Ardent's story, Ardent's a multi-hospital, multi-systems healthcare provider operating in eight midsize urban markets across six states. For us, I would say that we have very good positions in strong growing markets. Our markets are growing on average about three times faster than the U.S. For us, this has been very much a back-to-normal time. Volumes have been strong, durability. We expect to remain solid based upon both the growing market share and our growing position in those markets. We see ample opportunities for growth. We really have kind of a three-part growth strategy.
The first is continuing to grow the ambulatory footprint in our markets and expanding outside the four walls of the hospital as the ambulatory side is growing at a faster clip as things are shifting gradually into that outpatient world. We have a lot of room to capture additional ambulatory share in our markets. The second is opportunistic new growth. Given that about 35%-37% of the hospitals out there are still losing money, according to Kaufman Hall, we know that there's going to be select opportunities for us to enter into new markets and take our platform into new areas, particularly with our joint venture partnership. Third, we still have internal core margin expansion opportunities. We've done a lot of preparation as we went and launched public last year to be able to scale the organization and centralize and standardize our services.
We still have optimization to go. So we still see margin improvement over the next 3-4 years of probably 100-200 basis points.
Great. Before we get into some of those growth drivers, maybe we can do a quick recap of the strong results we saw in the first quarter. It seems like durable demand is supporting good volumes and margin. Maybe we can kind of just recap on what you saw and any observations from the quarter.
I'll start and let Alfred chime in here as well. Again, we look at the period of time we're in as very much back to a normal environment. We had strong organic growth before COVID. We had a couple of bumpy years, as most everybody did during those COVID years. Starting in 2023, accelerating into 2024, and continuing into 2025, we've just seen that return to normalcy from a growth demand perspective, except the population's aged. We've gotten five years older, five years sicker. I think our results reflect that.
Admissions were really strong as we went into coming out of Q1 and continue to show that favorable momentum that we've seen over these last couple of years continue to build. We have done a lot of work in terms of making sure we can take in the patients from our expanded regions that need to be housed in a higher level tertiary center. Our transfer center programs are working. Our service line rationalization has created a space. We saw strong demand growth in admissions in Q1, inpatient surgeries in Q1 as well.
Yeah, just a few things around the edges with Q1. When we look at a year-over-year basis compared to 2024, we did lose the leap year a day. Just it had a little bit of effect. Flu volumes were very strong in Q1. In the old days, that used to be considered a positive thing for the hospital industry. We would say it's net neutral. It does sort of skew some of your stats. Admissions were very strong, but acuity was notably weaker than the prior year. It also drives the higher utilization of premium paying over time. Net net, we think of flu as pretty neutral from a bottom line perspective, but it does create a little bit of a dynamic of higher volume stats, higher labor stats.
Just aside from the flu, it just seems like across the board, the continued volume strength that we've seen all through 2024 has continued this year. Are there any particular, for you guys, any particular categories that might be gaining more traction or increasing faster than prior years?
I would say that the volumes that we saw outside of flu were indicative of what we saw continuing to grow last year. We have had a lot of focus on growing high-end acuity services. We are continuing to see that pull through, aided by the fact that as we have grown our outpatient footprint and added more access points with urgent cares and are continuing to build our clinic structure, both primary care and specialty care, we are just seeing strong demand really across all service lines.
You've talked a lot. One of your big growth areas is the margin enhancement, a couple hundred basis points over the next few years. It looks like you made a little bit of early progress on that in the first quarter. We can kind of talk about some of those cost containment efforts.
Sure. A lot of those efforts have been targeted on our supply chain and supply chain initiatives. We've seen through 2024 and into 2025 continued reduction in supplies as a percent of our revenues. I'd say it's just a lot of hard work, as Marty indicated. We've spent a lot of time the last several years really consolidating, eliminating redundancy across our enterprise where we had grown through acquisition and had multiple back office functions. We've centralized those, consolidated, and standardized.
That's already yielded a lot of pull through. An example of that is in our revenue cycle where we've standardized across the enterprise using Ensemble Health Partners as our delivery partner for our full end-to-end revenue cycle services. As I mentioned, supply chain has been an area of particular focus. We still have opportunities for more improvement from a margin perspective just through physician preference items, improved obsolescence. We also have opportunities across the workforce optimizing that from both a premium pay perspective and an efficiency perspective and the use of technology to enhance and support our clinicians.
Just following up on that, of course, there's been lots of interest in the tariff. Any new thoughts on tariff exposure? It seems to be lightening up a little bit.
Yeah, we've obviously, like our other for-profit peers, we work with HealthTrust Purchasing Group as our GPO. They've quantified the exposure. Most of our contracts or their contracts are fixed for the year. The exposure to tariffs in 2025 is relatively minimal. We've quantified it with the help of HealthTrust as mid-single digits millions based off of current proposals. Now, those shift and change weekly. That could change. Again, we view the current year as minimal exposure based off of the fixed contracts that HPG has in place. You get out beyond 2025, the exposure would go up. Of course, again, it sort of shifts and changes every day.
I would say, I think those proposals were based off of initial proposals versus I'm not sure where the current ones are. I think they continue to come down.
Yeah, I would view that mid-single digits as sort of a cap, if you will, or a maximum.
Gotcha. Just to follow up on some of the commentary from 1Q, we had heard, obviously, we saw an active managed care headline week last week. You had mentioned that there was some denial activity creating headwinds. We wanted to see kind of where we stand on that and kind of what your latest thoughts are there.
Yeah, to be clear, we haven't seen a significant acceleration in denial activity as we look at our sequential progress with the payers. It has been on a year-over-year basis. We absolutely saw denials increase towards the end of Q2 and into Q3. It stepped up materially. On a year-over-year basis, it clearly was an impact. It's a tough environment. You read the same headlines we do. Payers have stepped up their denials. A lot of that seems to have coincided with the Two-Midnight Rule and the impact that it might have had on them from a speculative standpoint. It has been notable in the overall tenor and in both the magnitude of denials. A lot of it has stemmed around increased requests for information. Working with Ensemble, our percent of upholding those claims is very high, well over 90%.
It does lengthen the payment cycle. You've seen that in our DSO stats and really across the entire industry when I look at everybody's, everybody's up a number of days from an AR perspective. I would say the cash cycle has slowed down as a consequence of this. Again, we are working closely with our revenue cycle partner to ensure we both get bill in the way that leads to the fewest and least likely number of denials. Then, of course, support the claims and see them through the whole payment cycle. I don't sit here and pretend to think it's going to improve dramatically this year.
I do not want to harp on the policy. I know you guys have talked a lot about that. It has been well covered. We have had some news in the last couple of weeks or so. I just wanted to get your latest thoughts on what you are seeing, what you are hearing, and get your latest insight there.
Yeah, we obviously spent a lot of time with this and going to D.C. and talking with the people that are in the room that are largely making these decisions and helping to educate them on the impacts of their potential proposals. What we saw come out in the Energy and Commerce bill last week and then getting approved, coming out of the Budget Committee this week with some modifications was very much in line with where we expected things to be based upon the conversations we were having. At the same time, we've been messaging this for quite some time that our strong belief is that the DPP programs would be durable and that whatever changes happen would be evolutionary versus revolutionary. This Trump 2.0 Administration didn't even focus on healthcare as part of the election. That's largely what we're seeing coming through this.
Obviously, he's got tax cuts that he would like to approve. The House is trying to hold the budget process accountable to pay for those tax cuts in some way, shape, or form. We knew there would be changes. The changes that have been proposed have been largely incremental work requirements, eligibility checks. These are things that have been kind of part of that Republican mantra. If you look at the statistics around that, take the budget scoring aside, 92% of the people that are receiving Medicaid today are already working. The 8% that are not are largely disabled, caring for others, school age, what have you. When you look at the carve-out of exclusions in there, we do not expect that to be a major impact to us.
What we saw in Medicaid terminations last year as well, there was a lot of sort of hysteria around that topic about this time last year. What happened is largely those patients that were receiving Medicaid re-enrolled in Medicaid, some aged into Medicare, some did disenroll, and then others went and found commercial insurance, which was better. It was a slight tailwind to us if we look at that. As we think about these changes that are happening or proposed to happen, we think that these are very much changes that will not have a dramatic impact on our business. The other side of it is the Senate still has to pass their version of a bill. From the conversations we've been having, it's unlikely that they will be as pushing as far as the House side is.
I like to think of the House as sort of the emotional side of government and the Senate as the rational side of government. We put those two together, I think we'll come out with something that will certainly be changed, but things that we can absorb. Again, from the conversations we've been having, anything that is going to have a major impact to states, you go back to a third of the hospitals losing money out there, that there will likely be phasings of these programs. That is what we saw, sort of the tussle over in the initial energy and commerce bill to what was passed over the weekend, was the timing of putting the work requirements in.
The first proposal did not have them going in until essentially President Trump was going to be out of office and could be subject to be unwound. There was a little bit of push to accelerate that. I do not think the details have been fully released, but probably expect that there was some compromise on that. These things are not going to happen right away. They are going to be much more in the incremental nature, it seems, which is good to see for healthcare.
Great. Maybe we can talk about just work requirements briefly. Among all of the different areas of potential cuts to Medicaid, how does that impact Ardent? How do you think of that as among the potential options to kind of curtail the expenditures?
Yeah, as we said, I mean, out of the range of options, the most draconian things were taken off the table pretty quickly. There was some arm wrestling about some things in between. These were things that we largely expected would happen, again, just based upon that Republican mantra. Again, while the CBO has a method to score that, we just do not see the impact being a huge headwind to us, particularly if there are ways for those patients that do come off of Medicaid to find other aspects of either commercially employed insurance or health exchanges and the like.
Last Medicaid topic, we know we're expecting some supplemental payments from New Mexico. I just want to get your latest thoughts there. Anything developing since we spoke last?
Yeah, I mean, important to note in that energy and commerce bill, there were talks of grandfathering in existing programs. Again, we've been very confident that these programs would continue on, that they would get approved. We know that there had been correspondence going back between the state and CMS. We know that those comments have been resolved. Now we're just waiting for CMS to continue to roll through approvals. It was really good to see Tennessee, Nevada, a few other state programs starting to come out of CMS. After a little lull in the change of administration, now that CMS and HHS cabinet chairs have been installed, we're starting to see those approvals flow. We're fully expecting to see those things continue on into 2025.
I'd say the timing is a little bit less certain, but with very high confidence that these programs will get approved.
Great. With those kind of visibility improving on that front, maybe we can kind of talk about your outlook for this year. We had reaffirmed guidance. What are the swing factors to the ends of that guidance at this point?
Yeah, I think there's always just the overall demand volume things, again, which we're very happy with how the year started, very strong from a demand. There's always just kind of that core driver. Again, our visibility, we saw strong growth in our HIX enrollments and HIX volumes. I feel very good about that. We've touched on tariffs as being having a small impact, obviously, well inside of our guidance ranges. Where that ultimately lands out, we'll have a small impact. We talked coming into the year about the headwind of physician subsidies. That Q1, year over year, I think we're up about 6%, which actually has been a slowdown in the rate of growth.
We are still expecting that to be a headwind. It's certainly well within our expectations so far. Those are the types of drivers. You already touched on payer behavior and how that could have an impact inside of the guidance range. Again, very comfortable with our guidance and how we started the year.
Great. I wanted to touch on development activity. In the first quarter, you integrated 18 mixed care urgent care clinics. Those are expected to drive downstream volumes. Maybe you could talk about that process, that integration, how we've seen performance track there.
Yeah, we've said, what I said earlier, this is the first part of our tripart growth strategy. Last year, we acquired six urgent cares in East Texas. Once we have them on our Epic system, and there's been about a six-month integration and conversion for those clinics to get them online. We are still in the midst of that process with the 18 we acquired with NextCare in our Albuquerque and Tulsa markets. We saw a really good pull through into those programs. First, about 45% of the patients in those six urgent cares that we saw acquired in Texas last year were brand new to the Ardent family. This is, again, just a proof point of these are new access points to bring new patients into our system.
As importantly, not just the patients that come in that were new to the system, about 15% of those patients were seeing follow-up services elsewhere in the Ardent system. Whether that was a specialty visit, a diagnostic study, a procedure, surgery, in some limited cases, admissions, we're seeing that strategy work. With the NextCare acquisition, we don't have them fully integrated to have full visibility in terms of the downstream pull through. Expect to have that here in the relatively near term. We do know that the volume projections are very much in line with where we thought they would be and creating to the system. Coupled on that, we announced yesterday that we hired a new Chief Development Officer. Chris Shopline joined us from Kaufman Hall. We're excited to have Chris.
Chris has a 20-year history and background on the hospital M&A and the acute care services M&A side of the business. As we look for opportunities in not only Tuckins within our existing regions, but moving into new markets, we're excited to have him on board and really just put full court press towards our development strategy that we said was the second part of our growth thesis.
In his work thus far, have they identified any other kind of gaps that you're looking to fill? What would be the next steps in terms of bringing out that outpatient footprint?
For the outpatient side, we're continuing to develop. We've got some shovels in the ground and building some new freestanding ERs in our markets, looking for opportunities and partnerships with ambulatory surgery centers. Then we'll selectively look at imaging centers to round that out and perhaps a couple of micro hospitals along the way. Those are the general themes that we're focusing on, just building out that next layer of care to allow our physician services that are caring for over 1.2 million patients across our eight markets to make sure that those patients have the right centers to get care at the appropriate intensity, the appropriate location, convenient for them, and at the appropriate cost as we continue to focus on our value-based care strategies and contracts within the organization.
The last area of growth that you had talked about prior was the academic partnerships and these larger acquisitions. I just wanted to get your thoughts on the landscape there, if anything's changing about those types of negotiations, what those academic partners are looking for.
Yeah, no, Chris's timing of coming in as the Chief Development Officer is great. We've certainly seen an uptick this year in terms of the number of inbound calls coming from academic centers. After going public last summer, I think that brought some new visibility on the company and what we do and the history and track record. We have successful academic partnerships. We've certainly seen the interest rise by those organizations looking to continue to grow, particularly outside of their core market area. A lot of the academics will have a strong market share in their existing area, but they don't necessarily have the capital balance sheet or the integrating and operating experience to go into a new sub-market within their state. I think they're seeing the benefit that we can provide, particularly in these challenge times.
You've got a number of sort of the blue chip name academic centers that are doing quite well. There are a lot that are continuing to just struggle and sort of get by. I think our joint venture partnership and the track record of success we've built is an attractor to organizations looking to grow, and having the balance sheet support and strength to be able to continue to grow the company is a good thing as we're out there looking for that next right opportunity, next right market to go into.
Great. When you think about the kind of the overall profile of the markets that you're looking at, are they overall kind of grow? How is their kind of growth profile versus the broader industry and then also just broader versus your broader portfolio?
M&A is an opportunistic business. We can't just go in and pick a system and say, "You're going to become part of our system." Much to our dismay. The general characteristics that we are looking for are to stay very much to the knitting of what our existing company looks like. Those mid-size urban markets where we can get a grouping of hospitals that we can land and expand and grow the ambulatory side, go to the clinic side, and the value-based care side of the business. We're looking for markets that have positive growth rates.
Again, our existing markets on average are about three times faster than the U.S. I can't promise that everything is growing that fast. We're certainly looking for good positions where we can get a sizable position of entry into a market and positive growth rates.
Great. Thank you very much, guys. I think it brings us to about time.
We appreciate you having us.
Yeah, thank you.
Thank you.