Welcome to the Quest Diagnostics 4th Quarter and Full Year 2020 Conference Call. At the request of the company, this call is being recorded. The entire contents of the call, including the presentation and question and answer session that will follow, are the copyrighted property of Quest Diagnostics with all rights reserved. Any redistribution, retransmission or rebroadcast this call, in any form without the written consent of Quest Diagnostics is strictly prohibited. Now I'd like to introduce Sean Bavette, our Investor Relations for Quest Diagnostics.
Go ahead, please.
Thank you, and good morning. I'm on the line with Steve Ruskowski, our Chairman, Chief Executive Officer and President and Mark Guinan, our Chief Financial Officer. During this call, we may make forward looking statements and will discuss non GAAP measures. We provide a reconciliation of non GAAP measures to comparable GAAP measures Actual results may differ materially from those projected. Risks and uncertainties, including the impact of the COVID-nineteen pandemic That may affect Quest Diagnostics' future results include, but are not limited to, those described in our most recent annual report on Form 10 ks a review of our press release, we will now begin the call to discuss our financial results and subsequent quarterly reports on Form 10 Q and current reports on Form 8 ks.
The company continues to believe that the impact of a record, we will now refer to testing volumes excluding COVID-nineteen molecular and serology testing volumes. Growth rates Now here is Steve Roskowske.
Thanks, Sean, and thanks, everyone, for joining us today. A So in a year dominated by the pandemic, Russ brought critical COVID-nineteen testing to our country And delivered record revenues, earnings and cash from operations for the Q4 and the full year 2020. The pandemic has tested our nearly 50,000 employees and they have responded as heroes by developing the building test capacity, innovating new testing models with our retail partners, Transporting specimens, delivering results and of course, supporting our customers. We finished the year as one of the country's leading Providers of COVID-nineteen testing, I'm very proud of what we have achieved and optimistic So this morning, I'll discuss our performance for the Q4 and full year 2020, our ongoing role in the COVID-nineteen pandemic and update you on our non COVID based business. And then Mark will provide more detail on our financial results and our financial outlook for the first half of twenty twenty one.
So before we get into the details of the quarter and the full year 2020, we wanted to share our perspective on the new strategy for fighting the COVID-nineteen pandemic proposed by the new administration. We are pleased by the efforts to expand access to testing across the country, especially in the underserved communities We support the new administration's approach Controlling the pandemic by expanding the availability of testing supplies, enhancing laboratory testing capacity We also support the efforts of COVID-nineteen pandemic testing board, and we look forward to additional details in days and weeks ahead. Now turning to our results, continued high demand for COVID-nineteen testing drove our performance throughout the quarter
the
earnings per share increased by more than 126% on a reported basis a record basis to $4.48 For the full year 2020, Total revenues grew by more than 22 percent to $9,440,000,000 Earnings per share increased by nearly 71% on a reported basis to $10.47 and more than 70% on the adjusted basis to $11.18 Cash provided by operations increased by more than 61% to our $2,000,000,000 We announced today that we are increasing our quarterly dividend by 10.7% a record $0.62 per quarter and this is our 10th increase since 2011. Additionally, our Board of Directors has increased our share repurchase authorization by $1,000,000,000 The increased authority is on top of the approximately 9 a $100,000,000 that was available as of December 31, 2020. In the Q4, we continue to see strong COVID-nineteen testing volumes. Demand clearly spiked As the virus surged and people got tested in advance of the holiday gatherings. We performed an average of 135,000 COVID-nineteen molecular tests today in the 4th quarter, well below our current capacity.
We continue to innovate to further expand capacity, reduce turnaround times and gain efficiencies. And finally, we are focused on addressing health disparities in underserved communities through our quest for health equity initiative. We recently held our first COVID-nineteen testing event at Obesity Inn Baptist Church In Harlem, in conjunction with leading Black clergy and the United Way of New York City. Testing is more important than ever as the vaccines roll out over the upcoming months to get at risk patients into care We expect 2021 to be another very strong year for COVID testing, Although demand for COVID testing is likely to decline throughout 2021 as more people become vaccinated Now turning to our base business, organic volumes recovered rapidly throughout the summer and fall. However, the recovery stalled at the end of November and into December Due to the surge in COVID-nineteen infections across the country.
And Mark will provide a Let me share some of the highlights from our strategy to accelerate growth. Our M and A pipeline remains strong And we achieved our goal to exceed a 2% growth CAGR from acquisitions at our base business over the last 3 years. We continue to see increasing interest from our hospital partners about how we can help them with their lab strategy, which includes discussions around both our outreach acquisitions and professional lab service arrangements. The deals we closed in 2020, particularly the Memorial Hermann Outreach and Macko Acquisitions, position us Last year was also a record year for Professional Lab Services Strategy or PLS. And this is the our business to partner with hospitals to help them run their inpatient labs more efficiently.
In the Q4, we announced 2 small PLS partnerships With hospital systems in New York and Indiana and then in December, we announced our largest PLS relationship our Q1 results are to date with Hackensack Meridian Health, the largest integrated health network in New Jersey. Quest will manage laboratory operations and perform reference testing for 11 AcunTech Meridian Health Hospitals. We also continue to execute our health plan strategy by shifting the dialogue to value based contracting efforts from the recent past and discussions focused primarily on price. Our we continue to make progress with our new strategic relationship with Anson to improve quality and efficiency in the delivery of laboratory services. We're advancing our position with UnitedHealthcare within its preferred lab network and also are building momentum with many of our other national And Regional Health Plan Partners.
Finally, we continue to grow our direct to consumer services in the quarter. In December, we announced our 0 out of pocket QuestDirect COVID-nineteen testing option. Walmart drive thru locations. And also in the quarter, we saw a number saw acceleration in the number of consumers signing up for MyQuest patient portal. Today, roughly our 16,000,000 patients have a MyQuest account, an increase of nearly 2,000,000 since October.
In recent market research indicates that our brand is strong and has strengthened over the past year a
review of our results, we
have a strong foundation to accelerate growth in our consumer offerings. We continue to pursue our goal to reduce our cost base by 3% per year. We also see opportunities ahead to drive further productivity gains and at the same time, enhancing the customer experience. Once again, our Invigorate program delivered approximately $200,000,000 of cost savings in 2020. And we continue to see more opportunities to deliver future efficiency in our cost base.
Our new flagship laboratory in Clifton, New Jersey was live on January 4. This is the most highly automated laboratory in our network. And over the course of 2021, we expect to consolidate volumes from Peterborough, Baltimore and Philadelphia Labs to this Now before turning it over to Mark, I'd like to announce that we plan to update you on our our strategy and market overview at our upcoming virtual Investor Day, and it will be held on Thursday,
Thanks, Steve. In the 4th quarter, consolidated revenues were $3,000,000,000 Up nearly 56% versus the prior year. Revenues for Diagnostic Information Services grew approximately 58% a record quarter, which reflected ongoing demand for COVID-nineteen testing services, offset by a modest decline in Based testing revenue, volume measured by the number of acquisitions increased 26.8% versus the prior year, With acquisitions contributing 4.5%. As we highlighted in our 2020 outlook update in mid December, organic testing volumes ordered in our base business were down mid to high single digits versus the prior year in October November. The recovery stalled in late November with organic testing volume trends down high single digits versus the prior year in December a due to the surge in new infections across the country.
Additionally, many state and local governments imposed new orders designed to reduce transmission of COVID-nineteen, compared to December, organic base volume trends remained relatively steady in January versus our pre pandemic 2019 baseline. For the entire 4th quarter, total testing Excluding M and A and new PLS wins, base testing volumes declined approximately 8% in Q4 a record quarter versus the prior year. COVID-nineteen testing continued to be a meaningful contributor to volumes during the Q4. Their respective and effective tax rate. We exited the 4th quarter averaging approximately 130,000 COVID-nineteen molecular tests a record quarter and 10,000 serology tests per day.
Revenue per acquisition increased 25.2% versus the prior year, driven largely by COVID-nineteen testing. This was partially offset by unit price headwinds of approximately 1.6% In the Q4, which includes the impact of PAMA and was in line with our prior expectations. Reported operating income in the 4th quarter was $795,000,000 or 26.5 percent of revenues compared to $363,000,000 or 18 percent of revenues last On an adjusted basis, operating income in Q4 was $860,000,000 or 28.6 percent of revenues Compared to $329,000,000 or 17 percent of revenues last year. The year over year increase in operating margin Reported EPS was $4.21 in the quarter compared to $1.86 a year ago. Adjusted EPS was $4.48 compared to $1.67 last year.
Cash provided by operations was approximately $2,000,000,000 for the full year versus $1,240,000,000 in 2019. As a reminder, In the Q4, we returned approximately $138,000,000 of provider relief funds we have received under the CARES Act. Our financial position remains very strong. As we announced this morning, we increased our quarterly dividend approximately 10.7% a record of $0.62 per share and the Board expanded our share repurchase authorization by $1,000,000,000 So So we now have nearly $2,000,000,000 available for future share repurchases. We resumed share repurchases in Q4 around the trajectory of the pandemic and its impact on COVID-nineteen testing trends as well as further recovery in our base business.
Therefore, we are currently providing an outlook for only the first half of twenty twenty one and expect to provide updates as the year progresses. Our outlook for the first half of twenty twenty one is as follows: revenue is expected to be between $4,850,000,000 the $5,150,000,000 an increase of approximately 33% to 41% versus the prior year. Reported EPS expected to be in a range of $5.07 $6.07 and adjusted EPS the range of $5.90 $6.90 Cash provided by operations is expected to be at least 800,000,000 And capital expenditures are expected to be approximately $200,000,000 The demand for and duration of COVID-nineteen testing As well as the continued recovery in the base business are significant swing factors that remain challenging to forecast. With that high degree of uncertainty in mind, please consider the following. Our first half outlook generally assumes gradual improvement in base testing volumes, But we expect the base business to remain below our pre pandemic twenty nineteen baseline throughout the first half of the year.
COVID-nineteen molecular testing volumes averaging roughly 100,000 tests per day in the first half of the year. However, we expect average daily volumes to decline throughout the first half of twenty twenty one as more people become vaccinated. Therefore, we assume COVID-nineteen molecular volumes will be lower in the second quarter compared to Q1. COVID-nineteen serology testing volumes averaging 15,000 tests per day for the first half of twenty twenty one, With demand expected to increase modestly throughout the 1st 2 quarters of the year. Given the strength of our financial position and high cash balances, the earnings release, we expect to complete a larger amount of share repurchases in 2021 than we have done historically, while maintaining significant our earnings release, we expect to share more details about our capital deployment priorities at our upcoming Investor Day in March.
While we aren't providing a detailed outlook for the full year at this time, I'd like to offer some additional considerations for 2021. As a reminder, there will be no Medicare reimbursement cut under PAMA this year given the 1 year delay included in the CARES We expect organic base testing trends to slowly recover throughout the year with volumes likely a reflection, by the summer, we would expect a continued decline in COVID-nineteen molecular testing volumes in the second half of twenty twenty one compared to our our patients for the first half. Similarly, demand for COVID-nineteen serology testing is likely to wane in the back half of the year. Finally, COVID-nineteen molecular reimbursement is likely to trend lower in 2021 compared to last year. As many of you know, beginning January 1, CMS moved to a new reimbursement model with a rate of $100 for all tests reported within 2 days and $75 for all other results.
Several commercial payers have now moved to this new reimbursement model as well. Also, while we are encouraged that HHS now plans to extend the public health emergency throughout 2021, Prospective changes to COVID molecular reimbursement are still possible. Furthermore, direct
Thanks, Mark. Well, to summarize, I'd like to thank all Quest employees who have worked tirelessly over the past year. We have delivered a significant portion of the country's COVID-nineteen testing while serving the needs of people who rely on Quest every day. Thanks to their heroic efforts, we delivered record revenues, earnings and cash from operations for the 4th quarter In light of the company's strong financial performance, We have increased our dividend and share repurchase authorization, while maintaining flexibility to pursue our M and A strategy. We look forward to sharing a more in-depth update on our market views and strategy at our upcoming virtual Investor Day to be held on Thursday, a review of March 11.
Stay tuned for additional details on that day. Now we'd be happy to take your questions. Operator?
Thank you. We will now open it up to questions. And our first question comes from Ralph Giacobbe with Citi. Your line is open.
Thanks. Good morning.
Good morning, Rob. I guess I think I heard you say that you expected Molecular reimbursement to trend lower. Just wanted to flush that out to understand that and maybe what have you assumed Reimbursement with PHE likely extended for the full year. And has there been any discussion or thoughts about proactively going to plans and Perhaps not continuing to get that sort of inflated PHE reimbursement in exchange maybe for more favorable longer term pricing escalators? Thanks.
Mark, do you want to start it? Sure. So we are expecting to still do quite well in terms of reimbursement in the near term, we believe we can meet the turnaround times, certainly the threshold that's required to be eligible for the higher rate and then we get Obviously, based on the individual tests. So we're still thinking in the near term that our average rate reimbursement is going to be pretty strong, We also recognize the reality of the pressure on the industry from all the various payers, especially the commercial payers. And so therefore, As we mentioned, throughout the first half of the year, we would expect some reduction in that reimbursement, not something There will be momentous, but certainly some downward pressure.
And as we said, the client area is very, very competitive. So there's quite a few labs At this point, given the demand that have significant capacity, and so therefore in the culinary, it's very, very competitive. In terms of your question, I'm sure you can appreciate Ralph, but first off, we don't feel we're getting paid excessively for our COVID PCR, we feel like we're being paid appropriately. But even if you could exactly forecast the volume of our COVID testing and forecast the base business over a period of time, which obviously would be nearly impossible, I'm not sure that we need to trade off anything. We're very happy with the relationships that we built, as Steve mentioned, with the payers, we've moved away from a focus on price and moved toward more of a partnership, any Alignment around value creation, where they're looking for us to save the money and create value and big piece of that is moving more work to us Because we're already very high value compared to the rest of the industry and possible choices for patients.
Good question, Ralph. Certainly appreciate it. But for practical and for strategic reasons, because of where we think we are with the payers already with some of these new contracts, Certainly not something that we're looking to pursue right now.
Let me just add to that. Speaking to demand, What I would share is that over the course of the last 10 months, we've brought up our capacity Considerably, and we're going to continue to build it. And the reason for that is we want to continue to be prepared in the that we do have another surge. And then secondly is we want to make sure we really have a capability to meet turnaround times that are expected in the market. And over the last 10 months, obviously, a lot of our testing has been for the clinical purpose.
Well, we believe as we enter the second half and we're having many discussions in this regard, there's going to be a lot more demand For return to work programs with employers, which have been pushed out as you all know, return to leisure activities. There's a number of cities that have large tourism bases that are thinking about what they need to do to get people back into those venues and there will be a lot of activity around just return to life. And I know that we We're still trying to figure that out and that's going to offer us a lot of opportunity in the future. And with that, there's always a COVID test, but there's also Number of services we provide and those are yet to be defined. So we're still trying to understand what that second half opportunity would What we see so far, we will continue to have strong demand, but it might take a different form as we get into the second half and as we go into 'twenty two.
Thanks, Russ. Thank you.
Operator, next question.
A reminder, Pito Chickering with Butch Bank. Your line is open.
Hey, good morning. This is Justin Bowers on for Pito. Just with respect to the guide, can you kind of frame the high end and the low end for us in terms of your testing assumptions? And then also, the thought process on the increase in serology testing through the quarter.
Yes, sure, Justin. So it's multi variable. So there's You could come to the high and low end. So what I would say is they're all based on The 3 major drivers with most of it being on the base volume recovery and the level of PCR To a lesser extent, serology. So if we don't see a significant fall off from where we stand today in PCR Or if it surges up again because of these variants or some other unknown factor, certainly that would take us to the higher end combined with If the base business also were to continue to recover and not go the opposite direction as COVID surged again.
So there is some negative correlation obviously between the 2, but if they both move in the same direction that it moves to the higher end. And then if for some reason COVID fell off markedly even more than we were planning. And as we talked about, we are planning for a decline over time in this 1st 6 months As that midpoint and the base business did not show recovery or even potentially took a little bit of step back for economic or other reasons, then that will take can't at this point provide exact changes in the base and COVID because obviously there's multiple ways to get to either one. But Directionally, that's what ring sense is our guidance with the midpoint being, as I said, a modest recovery, but not full The first 6 months of the base business and then some step off, but still significant COVID testing for the 1st 6 months with the 2nd quarter Being markedly lower than the Q1.
Okay, got it. And then just to clarify the earlier comments, it It sounded like the base business right now is kind of running stable month over month from December levels. Are we interpreting that correctly? And then just in terms of the molecular tests reported on the website at $32,800,000 is that the right number? It looked like kind of a huge step up from February to January, but more importantly, Is that kind of where you guys are now for total molecular?
And I'll hop back in queue. Thank you.
Sure. Steve, do you want to take that? Would you
like me to? Well, let me the step up is The step up that we've seen based on the strong delivery that we have in the Q4 and the beginning of January. So we are as I said in my introductory comments, we are one of the leading providers of COVID-nineteen testing. 2nd is, it does not include Serology, you did ask a question about serology because we do believe there will be an increasing role of serology Throughout 'twenty one, we seem to see some early indications that There's interest in understanding whether you have the antibodies or not, which might inform patients and physicians around their urgency of getting vaccinated and at the same time we're bringing out a new capability called quant serology testing And this will allow physicians and patients to see if in fact they do get the spike protein from the And we'll be bringing that out of 2 platforms in the next few weeks. And this can help us Determine if the vaccine is being effective.
So we do believe that there will be some increased demands for serology. And this is on top of what we already do. And serology is providing a really important role for Management of the disease, overall surveillance, epidemiology and measuring the response of what's happening pre and post The vaccinations in broad population. So we believe there's an opportunity in front of us in 'twenty one in that regard.
And Justin, to close out on your other question, yes, dollars 32,800,000 was the total through as of Monday, And that was up $1,800,000 over the prior 2 weeks. So about $130,000 a day in the prior 2 weeks. Operator, next question.
Jack Meehan with Nephron Research. Your line is open.
Thanks. Hey, good morning. Steve, you mentioned the focus of the new administration on COVID testing. Can you talk about how you think Quest's role might change At all serving the pandemic and if we start to see greater adoption of home testing, how do you think Quest is going to be positioned for that?
Yes. So I think The new administration is leveraging what we've done in the past as a country and as an industry And taking it to the next level, I mean, you see the capacity that's out there now in the country that a few weeks ago, we're doing about 2,000,000 COVID our 2019 molecular test, so obviously up considerably from where we all started last March. But going forward, Jack, I did see that there will be a change beyond the PCR test as I mentioned earlier. There's going to be greater demand for Programs that get to portions of the population that help us get back to work, get back to leisure activities, get back to life. And so we're having a number of dialogues around that.
And that will include the role of antigen testing And more rapid testing workflows that allow us to see the fact that a person that wants to engage in whatever the activity is, is negative and safe for a reasonable period of time to participate. So when we get into that world, we'll obviously provide you good testing. But as I said earlier, there's a number of services And also IT solutions that you need to provide. And like so much in healthcare, you see one, but we're we're currently engaged with a number of organizations, a number of municipalities and a number of corporations And what they will be doing in this regard, particularly in the second half, I think the first half first quarter is outlined In our guidance, we're going to start to see improvement as we get into the Q2. I think the Q2 will be a telling quarter for us all.
And we do see a lot of people getting prepared for better infection rates, better position for populations To get back to work life and leisure activities and we're going to start to see more of that and Quest has a significant role in helping in that regard.
Great. And then just a
follow-up, I have a 2 parter on unit pricing. I was curious if you could weigh in, do you have any notable commercial contract renewals in 2021 and then maybe more broadly as you have discussions with commercial payers now, Do you feel like you have a little bit more of a good footing in terms of negotiating price given The role the labs have served amidst the pandemic?
Yes. Let me start with where you ended. I think the relationship with The health plans has never been better. As you've seen over the last number of years, we've increased our Presence, we have the best access to lives now that we have had in over a decade. And so we are in a very strong footing.
And also during the pandemic, I'll share that we were deeply engaged With many of the plans of what they needed to take care of their membership and also their employees. So the relationship has continued to strengthen. And as I said in my introductory remarks and Mark said as well, we're shifting the dialogue away Exclusively priced to the value we deliver. And when you go back to what we've talked about in the past What we bring to the table in terms of our value proposition and wound quality, our service performance, our innovation, All at a very affordable price, we believe our value proposition is really second to none. And as I said, the course of the last year, we've done surveys look at our reputation in the industry and net promoter scores and those are quite strong.
So when you bring that those facts To the table, Jack, our position in terms of working out the forward looking relationships has Provided a much stronger foundation and a better understanding on the other side that we really do deliver a lot more value. So So we're in a good position with our plans. We're in a good position with our contracts. We obviously don't provide specific details, but we feel very good about that. And also I shared that we continue to make progress with our United relationship with the Preferred Lab Network and the building relationship with Anthem, We're quite encouraged about as well.
So we feel good about our relationship and the progress we've made, but also the opportunities in front of us to continue to build on what we've been talking about. So Mark, anything you want to
add there? Sure. So Jack, I understand the question and several years ago, I think there was an expectation or people holding their breath every time we extended a contract with a major payer because it would imply some sort of major price concession, I can tell you this has become largely invisible to you all unless We talk about it like Anthem, which was really a new contract and brought together a number of states under a single contract as opposed to having different periods of time in which we were negotiating across the Anthem network. We just extended with a major commercial payer. You didn't hear about it because there was no price concession.
And in fact, we made huge headway with this payer. I'd say getting them to acknowledge that in the world of PAMA, the whole notion of a discount to the CMS, NLA rates No longer will apply going forward and that in fact CMS will be setting the market and that they should feel confident Is a market rate that they can feel comfortable and represent to their prospective or current members. So really that's what it's been about is they all want to make sure that they can say They've got good prices and now you've got an external benchmark you can look to. So we just extended with a very large Nashville. We do have one coming up this year, But I can assure you that it's not going to be it will not come with a major price concessions.
We're going to continue to work on the value based contracting, with that actually comes good pricing that we feel represents the market and then these come with upside, whereas we perform, We're both sharing the benefit of that upside. That's the way we're really contracting over the last couple of years and how we would expect the contract going forward.
Thanks. Thanks, everyone.
Your next question?
Kevin Caliendo with UBS. Your line is open.
Great. Thanks for the question. This is Adam Noble in for Kevin. I just wanted to, I guess, double back to your comments around Reimbursement for COVID PCR, one, just to confirm that you're assuming throughout the first half That the PHE is extended so that the Medicare rate with the add on payment remains 100. And then you talked about the kind of the commercial reimbursement potentially declining over time.
Just Any thoughts around kind of what the magnitude of changes on the commercial side you guys could potentially see in PCR?
Yes, sure. I'll comment on that and Steve may want to add. So yes, we would expect that as long as the Federal health emergency continues that this structure with the opportunity to earn $100 per test From CMS, we'll continue. Now that is a very small portion of our volume, but we would expect that. However, As I said in the prepared remarks, there is some risk.
They could decouple it. There's no guarantee that, that will continue. So and not only could they decouple the reimbursement with the FHA, but they can also like they did January 1, change the approach. However, At this point, yes, we are assuming the most the highest probability is that as long as the FHE continues, CMS will continue to pay us under this new method. On commercial, obviously, we're not the only player.
And so while we defend And we feel like we do a good job of explaining why our reimbursement makes sense as we've negotiated some new a job, but obviously there are other labs as well. And to the extent that other labs don't do as good a job as we do, there could be additional pressure on So that's why it's hard for us to predict exactly where this is going. But certainly in our mind, we would expect Our commercial contracts as well through the FHEs, saying the same basis for CMS paying us at that rate should apply to the commercial payers as well. I I also want to remind everybody that as long as the 0 patient out of pocket applies, that is also a huge tailwind for us because To avoid having to bill patients where historically we've shared that we get about $0.70 on the dollar And as you get 100% of that payment from the 3rd party is also a large enhancement to Revenue and our profitability as well. So that's a factor I don't want people to forget about.
Steve?
Yes. Just to add to the CMS new methodology for reimbursement. As you know, we are reimbursed at $100 when we report the results in 2 days and $75 for all other results. And To Mark's comments, we have seen a few payers to look at this model as well. But we're encouraged by The public health emergency extension through 'twenty one.
And also just to share our timeliness of our results are quite good. We have met that threshold of 50% of COVID molecular test resulted in less than 2 days. We did that in the last few months. And I'll share that the majority of our testers are resulted in 2 days or less. So my other comments, I did mention that we'll continue to build capacity Because it just gives us a lot more operational flexibility to meet better turnarounds times based upon where the demand is coming from.
So I think we're progressing well. We're a very good provider of the test. Time is one element in quality and reliability And also the type of testing we have done, our methodology for PCR tests, Both on the LVT side and obviously the kits are somewhat consistent throughout the industry are really quite strong. So if you look at the accuracy and the quality of testing, people have come to consider us the gold standard, and I think that will bode us well going forward as well.
And if I could just the next question? Apologies if I missed this, but have you guys provided the average reimbursement levels for the PCR testing in Q4? And can you comment whether you're embedding similar levels in the first half guidance?
Yes. So We didn't specifically call that out, but I can tell you that it did not change much in Q4 from where it was in Q3. It was above $90 We do have some client though customers That are less than 100 and we don't get paid for 100 percent of the testing, sometimes due to missing data and so on and so forth, we do get some denials. But certainly north of 90 was the AWR previously. Now we we did talk about the fact that we expect that to have some pressure and to reduce over time through the first half.
That doesn't mean that it absolutely will, but in our guidance, In the midpoint of that guidance, we did make an assumption that given the new model with the $75 not just with CMS, with some Commercial payers, we're not going to get paid for 100 percent of our tests at that 100 where we have been done previously. Still a large majority, as Steve said, meet that a 2 day turnaround time, so that will create a little bit of erosion. And then also I mentioned that there's a lot of capacity Therefore, a very competitive environment in that client bill arena aside from the 3rd party.
Got it. Thank you. And just as a quick follow-up. On the base business, can I confirm, you said you don't think you'll expect to pre pandemic levels in first half, is that compared to 2019 or does that include acquired volume as well? Thank you.
Yes, that is correct. We would, as I said, was as we're looking at the back half, even though we're not giving guidance because there's Too much uncertainty around it, we expect it to be back to pre pandemic levels towards the end of 2021. So in the first half, We still expect to be down versus 2019. We felt even though the pandemic didn't start largely for our business till March, Easiest compare and how to talk about it is 2019 volumes. We did have a large growth For the 1st 2 months of 2020, as we shared at our first earnings quarter earnings call, so that can bounce things a little bit on the year to year comparison.
But, yes, we're going to continue to talk about our volume performance relative to 2019 because it's the cleanest compare for the whole year.
And when we speak to that, I heard it in your question, we are looking at organic growth. And so we spoke of a couple of acquisitions that we closed last year and in our organic discussions, we're excluding those and any other deals we might do prospectively. So it's organic
And then we think that the best representation of utilization. So that's why we think it's important. Our organic performance versus 2019 kind of gives a sense because of our size and reach, think where the market, hopefully, all is performing.
Yes. So the acquisition revenue will be on top of that. We obviously announced a couple of deals and what we said is we have a good funnel and anything we might do prospectively would be on top of what we said.
Derik De Bruin with Bank of America.
So just one quick one.
Can you provide a little bit more color on how should we think about the margin progression throughout 'twenty one. And particularly, how much of your with the core business still being down, how much of that is margin headwind,
but just sort
of thinking about the dynamics as we go from the first half to second half with COVID volumes
Coming down and you returned to
price to be more normal for the core business, just wanted to get some thoughts on
the margin progression and workflow, please? Thank you.
Sure. So it depends when you say is it a headwind, it depends on to what you're comparing it. So as we expect the base business to improve, that's a significant margin tailwind versus the prior period because we are in any given window the time, a highly fixed costs operation on our base business. And while we took some significant cost actions In the Q2 of last year in response to the significant downturn in our volume and we've continued to manage our costs very, very To the back half recovery to not get out in front of ourselves, we're not planning on any significant restructuring in the near term with volumes that are down single digits at this point. So our cost structure in the base business is to some extent what it is and we'll add a small pieces that are necessary as it recovers, but that growth and recovery in that base business sequentially It's a nice tailwind.
Now on the other side, as we talked about, expect erosion in our COVID volumes, that And how those two pieces offset each other is hard to predict slightly, specifically. But I would at this point expect that the COVID reduction more than offsets the base, but at least they do partially offset each other as we move forward. And then the other dynamic is obviously reimbursement on the PCR test, and we shared that we expected some No pressure on that as we go from the Q1 into the Q2 sequentially and then likely even more so in the back half of the year. So without getting into specifics, those are kind of the things you should specific numbers, those are kind of the things you should think about as you think about where our margins are going to go
Lisa Gill with JPMorgan. I just wanted to follow-up on your comment around the acquisition opportunities. Steve, one of the things that was anticipated that with PAMA, there'd be a lot of pressure and you'd see more acquisition opportunities. With PAMA now being pushed out, does that change anything, number 1? And number 2, When we think about reimbursement, as we've been talking about, for molecular tests, etcetera, I would think a lot of these labs have done well during this period of time.
Does that changed what their expectations are at all around what their business is worth, as we think about acquisition opportunities?
Yes. Thanks, Lisa, for the question. So the first part is really about acquisition opportunities around the Hospitals. And you see that we announced a couple of deals last year that we're happy we did and that's going to help us. And We continue to see a nice funnel for 2021 as well.
And as you all know, hospital volumes have been down through 2020. They have recovered for us. However, What we do see is a lot of renewed interest of looking at their lab strategies, which includes Acquiring your outreach business and includes professional lab service agreements like we just announced In the Q4. That relationship we announced in the Q4 with HACZAC Viridian Health System It's the largest we've ever done. And I could tell you it took a long time to get there.
And I believe the perspective reality of what's In the healthcare market this year helped bring that to a conclusion. And I believe that that will happen with a number of dialogues We have going on with hospitals right now. So that's one piece. What's happened is on other commercial laboratories. Yes, you're right.
Number of Commercial Laboratories have jumped into the COVID testing arena. You see it with all the capacity we've added to the country. However, as that starts to be pulled back and they start to see what the prospects are given What we're driving as an industry with consolidation with tighter contracts and networks around health plans, We believe that there still will be a catalyst in the marketplace for us to continue to consolidate. So yes, there's been a short term opportunity for a number of labs to take advantage, if you will, the opportunity to provide COVID-nineteen testing. But as that starts to change, as we get throughout 2021, we believe the realities of what the new world will be with tighter networks, More consolidation will play nicely into our strategy and allow us to acquire more going forward.
And obviously, given our cash position and strong balance sheet, we're in a very nice position to continue to do that. And then also, Lisa, there's been a lot of discussion around all this additional capacity out there. People have added new systems and potentially does this prevent a risk for us that these people are going to get into Businesses outside of COVID by appointment's health. We are watching it. Obviously, some hospitals have moved their To use that capacity to get into competing with us by way of example, That's a long stretch.
I mean, there's a lot to lot more to getting a client to flip over than the lab the capacity, you have to have a sales force, you have logistic capabilities, you have to do electronic interfaces, you have to work with You have to be in a contract with the health plans. So we are watching it, but at the same time, we're A little cautious in the belief that some of this will have a significant effect. At the same time, we're watching Carefully make sure it doesn't and we're staying on top of our clients to make sure we serve them well. Thank you.
Yes. So If I could add, Steve, just a couple of things, Lisa, around your question around our pipeline. At any given point in time, we've got multiple opportunities that we're discussing, I can tell you that none of the potential sellers that we're speaking to right now are getting and expecting to get paid for that PCR bubble. So fortunately, I could see a mentality that, hey, my value has gone up dramatically because of COVID testing, but the people we're talking to right now recognize that that's short term and that should not be a part of the And then the while PAMA gets a pause this year, there's still some risk. But more importantly, As we've mentioned and I'm sure you've seen, it's not just CMS, but the commercial payers are starting to put a reduction in the high hospital outreach rates, recontracting that work that's outside the patients who are in the hospital, either Admitted or outpatient at independent laboratory rates.
So it's not this pressure is not just coming from Washington, it's coming from the commercial payers as well. And from quite frankly patients who don't like those high prices when they have a high deductible plan. So there's a number of things that are getting the C suites of large hospital systems with outreach to think about do they really want to be in this business and will this be a good time to monetize. And so therefore, I really don't see the pipeline of interest having been impacted over the last 12 months negatively.
Matt Larew with William Blair. Your line is open.
Hi, good morning. As I think about the various components of your response to COVID-nineteen and your role in testing, two things that stick out as step changes from a pre COVID world are certainly capacity And then consumer engagement, I think the number of patients using QuestDirect has doubled in the last 15 months. So just curious, what can you do and As we move to sort of a post COVID world to leverage that increased consumer facing presence, consumer engagement as well as the added capacity that it sounds
Yes. Thanks for the question and we're very bullish on our consumer strategy. As you all know, Yes, 5 strategies for growth, one of which is the consumer strategy and our direct to consumer Business that we've built over the last several years has done quite well and we do believe The pandemic has now been an accelerator for that. We are providing COVID-nineteen testing through that platform. We're going to look at using it through consumer genetics.
And as I said in my introductory comments, interesting part of the pandemic And Quest Maine has been out there more than ever and our brand has been built. And our brand is really second to none in our industry And we coupled that with our service performance. And so we have this strong foundation coupled with the change in the marketplace. And we do believe there's going to be a continuation of the number of consumers that are engaged that will engage differently With healthcare delivery systems and now they engage with the physician, with telehealth, we have a very strong presence with telehealth providers and With integrated delivery systems that offer a telehealth option, but at the same time a lot of patients as well and consumers We'll have received their basic health checks and testing online as they buy so much else in their lives. And so we're very well positioned With reputation, with capabilities, and so we are investing in that in a significant way more so than We would have if we did not have the pandemic.
And so we think about the growth drivers going forward. And we'll talk about this some more at our Investor Day. We're very bullish about the opportunity we have in front of us around our QuestDirect, but also the consumer opportunity in general. Thank you. Just one quick one on the deal side.
Possible you could frame for us the Hackensack opportunity, the contribution to growth in 2021 in the first half guide. Thank you. Mark, you want to take that?
Yes. So we don't typically announce the revenue impact And again, I want to remind you this is organic. So this is not something we bought. We worked with Hackensack and demonstrated to them that we can perform the same work they do in their lab at a better cost, better value. And for a system that size, there's significant lab spend.
So this is going to be quite impactful and beneficial to them. And we see that as opportunity obviously to also get other clients who will get their attention to see, hey, if Hackensack Thanks for this will work well in addition to some of the other hospital systems that we've won over the last couple of years. So we're very, very excited about It is a large deal. It's the largest deal we've ever done. It will be material to our growth.
And we talked a couple of years ago at our Investor Day and we'll likely give an update on this. But we thought we could get more than 100 basis points, somewhere between 100 to 200 basis points of growth every year from our POS business. And certainly, this one Is a large contributor to that and might even give us an opportunity to exceed that. So very large deal, but we're not going to. We haven't had historical a precedent of calling out the exact revenue, but it will be noticeable and material as we go into 2021 and beyond.
Hi, good morning. So I mean, clearly, there's a lot of uncertainty around second half in the trajectory of the comeback of a more normalized utilization level. If we step away from the timing and just think about the margin trajectory, how should we think about core margin trajectory from where they were, let's say, in the Q4, to where they can expand to as utilization comes back So again, the question is more about the margin trajectory, as it relates to utilization, not about the timing. And then my second question is more about sort of market demand. So how do you think about changes in physician behavior patterns?
We're seeing telehealth becoming more integrated into the workflow. So, do you think that there's going to be any impact on longer term lab testing demand curve Because of that, I don't know if it's the experience early in the year, could shed some light on that?
Yes, sure. Mark, do you want to take the first part or do you have a second?
Yes. So Ricky, obviously, the size of the revenue we've generated from COVID, which more than offset The base business has materially impacted our margins and expanded them greatly relative to our historical margins. So as we progress and we'll talk more about this at Investor Day, but we progress into a future where COVID testing is still around For a while, as Steve said, we don't expect it to go away completely, certainly by 2022. It's going to be less material to our top line and to our margin. So where will our base business be?
Once we get back to the pre pandemic levels of 2019, I would expect our base business to be slightly higher margin than it was our pre pandemic, because if you look at our Invigorate program, which we continue to drive even during the pandemic, And you look at the offsets of the pay fors that we usually talk about, including wage inflation and price erosion, given the pause on PAMA this And given the fact that we've done really well in other price concessions despite significant increases In our SWB that was warranted during the pandemic, as we wanted to reward our employees for their incredible contributions In getting us up and running, operating well through it and obviously driving strong company results. And when I net all those together, That level of business should be more profitable. And then going forward from that, when we get back to The growth that you saw in 2019 and you saw in the 1st 2 months of 2020 and our ability to leverage that growth, I would expect to So longer term, the good news is we were on a good path on growth and margin expansion pre pandemic, And we will get back there.
But for a while, it will be somewhat masked by the COVID decline that's inevitable over the next Certainly 18 months or so.
Yes. And your question about physicians, Ricky, we're watching this carefully because we do believe going back to an early question about the consumer activity that There will be a transition here now going forward with physicians serving the market in a different way. As we said before, About half the physicians have either sold their practices to integrate delivery systems or have strong affiliations with integrated delivery systems. And that will be consistent going forward. But the other half of the market, We believe there will be a growing percentage of that portion of physicians that are served by telehealth and we have a very strong a position with those telehealth providers and that was before the pandemic.
And those telehealth providers are not going to work with our handfuls of laboratories, we'll work with a few and then we'll have a real type for lab network as you would expect. And as you would expect, Quest would be one of those options. We feel good about that. 2nd, as you see more consolidation going on in physicians and you see what's happening, particularly with one of the health insurance companies Optum acquiring physicians and a number of those physician practices our customers, you think about their consolidation and think about their role and think about where they add value of bringing all those physicians together. We believe there will be an opportunity for us to work with a consolidator like Optum to provide lab services more broadly And really reduce the variation they have with all their physicians.
And just one last point to show that This world is moving to a tighter network of lab providers. In the Q4 of last year, UnitedHealthcare actually announced the removal of out of network benefit For some of their fully insured members. And so it's just another example of a major health plan tightening up the network. So we think The physician side will change and there will be a different way of providing physician services to patients going forward. And that trend, we believe is a good trend and will provide Tier 1 for us to consolidate the market.
Erin Wright with Credit Suisse. Your line is open.
Hi, Erin.
Great. Thanks. Thanks so much for squeezing me in. Just a follow-up around that competitive landscape and consolidation, so it sounds like you don't expect there to be any sort of meaningful impact on your opportunity around consolidation, just even given the dramatically expanded installed base of PCR instruments across the U. S.
Over the past year, I mean, I would assume that customers do want to monetize those investments to some extent. I'm just curious what you're seeing in terms of market share shifting outside of maybe COVID testing that you're seeing already, if that's happening at all, I mean, it sounds like everything still remains an opportunity from an M and A perspective and consolidation standpoint. And then my second question is just on how should we be thinking about the long term dynamics as it relates to COVID testing. It will obviously diminish with the vaccine rollout, but could it evolve into something more similar to like flu testing in future years? And can you remind us of the flu testing exposure you do have?
Thanks.
Sure. So As I said earlier, we believe that hospitals will be now increasingly looking at their options to become more we're confident given the pressure the pandemic has put on many of them. And we're encouraged by the level of discussions we had and the deals we have closed as an example that this is happening. So we think that's good. On the commercial laboratory side, we believe that some have gotten into the COVID testing It's provided somewhat of an opportunity for them to get through this year.
But as the dust settles and testing volumes go down, the reality of what we talk about dynamically doesn't change and we think there would be many of those that would be looking at their options. And we do believe that COVID testing will continue into 'twenty two. We believe that this will be a virus that we'll have to manage. So it will be more flu like and something that We'll be behind us in the end of 'twenty one. And it's hard for us to scale at this time what that will be, But you should not think that this is going to be a testing opportunity that will go away at the end of this year, but we do believe They'll be with us in 2022 as well.
And as far as the flu, we talked about in our earnings call that we have offered a combination panel when the patient presents itself with symptoms, The physician wants to rule out the flu and also COVID. And so we have seen that be accepted. But as you all know, the incidence of flu this year is down considerably Because of all our behaviors in the United States. So that has changed somewhat. Sean or Mark, you want to add something
Yes, I don't have anything to add, Sean.
Our last question comes from Brian Tanquilut with Jefferies. Your line is open.
Good morning and thanks for squeezing me in. I guess just one quick question, Mark, as I think about your capital deployment, obviously you're generating a lot of cash And it sounds like the hospital acquisition opportunities are the pipeline there, but maybe a
little slowing coming through. So How should
we be thinking about your willingness to buy back more aggressively in the front end? And how should we be thinking about Just other capital deployment opportunities, whether it's internal on the CapEx side for growth.
Sure. So we are investing quite a bit internally. As you may have seen or you'll see in our capital For 2020, we ended up $418,000,000 which was above the initial range. A lot of that was related
directly to the COVID capital that was necessary.
That was necessary, but we certainly have not stepped back on investing internally because we think that's the Best way to drive returns, a lot of that obviously is related to our Invigorate program. We are moving all of our new assay test to a single platform, we continue to move forward on that. And then a big piece of the 2020 and the first half of twenty twenty one Was related to Cliffs in our new facility, although we started operating in early January, we still have some final set out and equipment to put in and that will Drive some of the spending in the first half. So we absolutely have a high priority on internal capital and we'll continue to do so. You can see we guided to our $200,000,000 in the first half, which is about 50% of what we spent in 2020, as we step back a little bit from COVID capital, but we have some Continued spending on Clifton and then also the normal priorities on which we spend.
On share buybacks, As I mentioned, I will give a lot more color on the Investor Day. The reason for that is we do have some things that we're monitoring around potential cash deployments, we'll have greater clarity on as we Over the next couple of weeks, we also wanted to get a little more of 2021 Q1 behind us to see how that performance continues And what our expectations for Q2 look like at that point, because every day, every couple of weeks, every month certainly gives us better line of sight into expectations. But by announced by us seeking and getting approval and announcing $1,000,000,000 increase in our authorization, Certainly, you correctly are taking that as a signal. And as I said specifically in my prepared remarks that we're going to do more share buybacks And I'll remind you that our capital allocation strategy, which we have not changed to this point, is to give the majority of our our free cash flow back to our shareholders through our dividend and our share repurchases, we suspended them for 2020 for a period of time. But even with our $2.50 spent in Q4 and the increase in dividend, over time, we're behind that 50%.
We have some catch up to do.
Yes. Maybe just to add to that the performance we 2020 and the performance that we're indicating with our guidance in 2021 is affording us an opportunity to invest And our growth strategies and that includes what we've talked about on this call, working on the relationships with health plans are gaining traction with presenting our lab strategy view to health systems, the hospital health systems, what we're doing around advanced diagnostics and then finally what was asked about earlier around the consumer opportunity in front of us. So Applied in the guidance is an increase in investment for those growth drivers to accelerate growth of our base business Within 'twenty one, but as we enter 'twenty two as well. So if there are no further questions, I'd like to thank everyone for again joining us on this call. We appreciate your continued support and interest and you have a great day.
Take care.
Thank you for participating in the Quest Diagnostics 4th Quarter and Full Year 2020 Conference Call. A transcript of prepared remarks on this call will be posted later today on Quest Diagnostics' website at www.questdiagnostics
dotcom.