All right. Welcome, everyone, to Day three of the Stephens 2025 Annual Investment Conference, live and in person in Nashville. I'm Raj Kumar, Healthcare Services Analyst here at Stephens. We're closing out our conference with HCA Healthcare, who's the largest for-profit operator of acute care hospitals in the U.S., with 191 hospitals and an extensive network of 2,400 sites of care across 20 states and the U.K. Overall, kind of framing HCA's presence, they oversaw 44 million patient encounters in 2024. And from the company we have here presenting is Mike Marks, Executive Vice President and CFO. In the audience, we have Frank Morgan, John Hackett, John Connor, and Luke Elliott as well. I want to thank the HCA team for joining us at the conference today. I think, if it's all right with you, we'll just jump right into Q&A.
Let's do it.
All right. You know, we've been starting off kind of these conversations with essentially a year in review and maybe just kind of talking about updated guidance. 2025 is set to deliver another year of revenue and earnings growth that's above the long-term guidance that was set at the 2023 Investor Day. You know, clearly support from policy tailwinds, but also underlying operational initiatives that have kind of helped that around caseload optimization, LOS, and service line optimizations as well. Maybe diving deeper into kind of the operational aspects of the kind of performance. You know, thinking about the ever-evolving needs of stakeholders in your communities, can you just walk us through some of the big changes that your health systems have incurred, at least, you know, when we think about kind of retrospective pre-pandemic, where kind of the healthcare environment has broadly changed?
Sure. First, welcome to Nashville. It's always good to have all of you folks here in our hometown. It's a little easier too, so we're a 10-minute drive instead of having to fly. This was great for us. Thank you. When I think about the work of the company, I always try to remember that our job is to take care of patients. When I think about kind of long-term guidance demand, that just reflects the fact that in our 43 markets here in the United States and then in Central London, we see a continuing demand for healthcare services. I think that reflects the strength of our markets. We have markets that have above-average population growth, that tend to have strong economies, and produce pretty strong levels of employee-sponsored insurance. We approach those markets with this idea of network.
We are a hospital-centric health system, but we surround our hospitals with a network of outpatient facilities to really meet patients where they are and provide convenient and easy access for when they need outpatient care, and then a network that makes it easy for them to access acute care when they need acute care. This idea of network development from our capital investment programs and for our acquisitions allows us to really do two things in terms of taking care of patients. One is it allows us to service that demand growth, you know, because we're adding network facilities, we're adding beds every year. That is important. By strengthening those networks, it makes us more competitive. It allows us to take market share. The combination of that and our long-term plan, you know, speaks to this idea.
We believe in our markets that we get somewhere between the 2%-3% volume growth as a reflection of, you know, both the strength of the markets we're in and the strength of our networks and the competitiveness of our networks. You know, we couple that with a lot of operating discipline. We operate at scale. We have significant shared service platforms that allow us to be really operationally excellent. You see that in the operating leverage of the company. We're pleased this year as you kind of think about where we are here at the end of the third quarter with our margin performance, our cost management performance. You've seen us really being able to leverage that volume growth, cover our fixed cost, and produce leverage. You know, broadly, things are going well.
They're going well, you know, from a finance perspective, but more importantly, from an operations perspective. If I look at our trends on things like quality and patient experience, employee and physician experience, you know, broadly, the work of the company is performing really well right now, as we sit here through the first nine months of the year.
Great. Great. Just maybe just following up on that front, it's like, what is the kind of embedded runway on some of these initiatives that you've, you know, previously called out that are, you know, underway to sustain that 2%-3%, you know, from at least thinking about it from a same-store perspective? Because clearly there's a, you know, development pipeline that's very intensive as well. You know, how should we think about, you know, what's still remained from that, you know, from what's been disclosed? Has that been really realized, you know, in 2024 and 2025, or there's still kind of some of that leg room that can extend to, you know, beyond into 2026?
I think the way I think about this is really in kind of two major buckets in terms of sustaining growth and where we are kind of using the baseball analogy of like, what inning are we in? On a capital investment program standpoint, you've seen us deploy, you know, between $4 billion and $5 billion of capital for several years in a row now. We'll be right at $5 billion this year. I mean, we continue to see significant opportunities coming up from the field to continue to invest and expand our hospitals and our networks. We have $6.7 billion of capital in flight. The pipeline of project requests that we continue to get from our hospital operating teams are really good. I think we have a good runway.
We have markets that are growing, which allows us to continue to invest and strengthen those networks. That is really good. The second thing I would add would be the work we have done on network development. You know, if you go back in time, we had something like 10 outpatient facilities for every hospital. We are sitting here today at about 14 outpatient facilities for every hospital. You know, between now and, call it, the end of the decade into the next decade, we will probably be at 20 to 1. The reach of the company and adding things like urgent care centers and freestanding emergency rooms and surgery centers and physician clinics to continue to deal with the growth that we see in our marketplaces is good. I see that as being a continued driver of the volume growth or demand in our markets.
It's a little bit of like what we said at Investor Day. I mean, there's a durability in HCA. And I think that's a representative of both the markets we operate in and how we operate and the strength of the company in driving that market share growth.
Speaking to the durability, I think it's kind of important since, you know, 2026 has unique dynamics that still are uncertain from a broader perspective. You have resiliency initiatives that you have in place that you're going to speak more towards on the fourth quarter earnings call. Maybe just kind of from a qualitative perspective, what are some of the things that we could expect on those types of initiatives and, you know, maybe bucketing them in terms of what are revenue drivers and what are cost optimizers? Sure.
We have three major buckets of resiliency. The first one is really, you know, our organization. We continue to invest heavily in our leaders and do things like workforce development to really help strengthen our organization. You know, HCA has great management teams. Continuing to invest in their development and the pipeline process of that's important. We continue to work hard on workforce development. Think about the Galen College of Nursing. Think about the GME residency programs for physicians coming out of medical school. Those investments that we've made and are going to continue to make in workforce development builds resiliency in our organization. The second area of resiliency for us is our networks, our operations. We continue to make significant investments there.
We've talked about the capital investments and things like the acquisitions that we do a lot on the outpatient side. We also work hard on just overall operational resiliency. A great example of that would be asset utilization. We are several years in now into a length of stay management plan that has allowed us to reduce length of stay. Our performance this year has been really good. You know, call it 2% length of stay reduction. That is a way to add capacity and give you staffing capacity without spending a dollar of capital. We're instilling kind of early to mid-earnings using baseball again for our length of stay initiative, our case management initiative. We still see a lot of opportunity over the next few years to continue to, you know, use our assets in an optimal way.
That applies to emergency rooms with turnover and operating rooms with the way we schedule and operating our operating rooms. This idea of asset utilization is a key part of resiliency. You have financial resiliency, which we've spoken about. I really think about it in three buckets. One being revenue. We've worked really hard and are continuing to work hard to clear our revenue and to, you know, have revenue integrity. A lot of that is pointed at denials and underpayments from payers. That's a piece of that work. End-to-end, making our revenue cycle more efficient and more effective is a big part of that. Revenue is a big chunk of what we're working on. Variable cost and fixed cost are the other two.
You know, we broadly approach these areas with things like benchmarking, which we have a very robust benchmarking capability in the company, adoption of digital tools and AI. You know, really a fairly significant component of our digital agenda is pointed at our administrative platforms and our operating platforms. The third being clinical platforms. That is important. The last one I would say is shared services. I mean, it is a hallmark and a strength of the company, our five big shared service platforms. We are always finding new ways to leverage that and giving them more scope, more functions to manage, and also investing them to drive more process improvement as they go through their work. You know, broadly, we have been hard at work over the last several years, especially over the last 12 months to get prepared for 2026.
I think these resiliency domains have put the company in a good position, the best position we really can be as we go into, you know, a period of time where we're all waiting to see, you know, do EPTCs get extended or do they expire? The job of the company has been to prepare for either outcome. That is what we've been doing.
Great. Kind of, you know, on that, just we touched on the operational efficiencies and initiatives and kind of how that's driven 2025. Now maybe touching on the policy tailwinds with, you know, Medicaid supplemental payment programs. There are a couple of states that, you know, are still on the docket: Florida, Virginia, Georgia kind of come to mind that may come to fruition in this year, although, you know, TBD on that front. Maybe firstly, any updates on how CMS is progressing through the approval pipeline now that the government is kind of back in or back online?
If these do kind of get pushed into 2026, how would you kind of frame the initial, you know, DPP-related headwind tailwind in 2026 if we try to bridge from, you know, the kind of what we have from a benefit perspective in 2025 and then relative to if these programs kind of get approved in 2026?
We'll give 2026 guidance on the fourth quarter call. I'm not going to size what the benefits are tailwinds or headwinds yet in terms of state supplemental payments. What I would say in making sure we provide context is, you know, part of the one big beautiful bill that was a positive. You know, every bill has some positives and negatives. Clearly, you know, this bill was mostly using, you know, cuts to Medicaid to pay for the individual tax cut extensions. Over a long period of time, there's some pretty significant reforms to Medicaid included in this bill. The good news about those reforms is they were bifurcated depending on expansion states versus non-expansion states. The reform was less impactful if you're in non-expansion states. For HCA, 60% of our Medicaid revenue is in non-expansion states.
That was a bit of a helpful piece of context there. The other thing I would say, the fact that the reforms generally do not start taking impact until the 2028 fiscal year and then get phased in over a fairly elongated period of time, you know, call it five to seven years from 2028. Generally for HCA, you know, we believe we are going to be able to manage the Medicaid reform components of the one big beautiful bill generally well. I do not think it is going to take us off our long-term plan related to the Medicaid reforms in the bill. The positive aspect of this bill, though, was the fact that they allowed states, if they filed on time, to get approvals to enhance their programs and it is under the grandfathering provisions. HCA had, you know, five states that are more material for us.
There are a few others, but five states that met the deadline had their application filed on time. Two of those five have already been approved, and that's Kansas and Texas. Based on our understanding of the review process from CMS for those two applications and a few other states that we're just not in, but that also had gotten approval, it feels like to us that these are active reviews. You know, they kind of shut down with the government, now reopened, and the reviews are continuing. You know, you may have noticed that Virginia got approved this week. You know, from what we can see, it looks like CMS is continuing their reviews, and we've now added three states that have been approved. The other two I know are in review, and we're waiting to see the timing and what happens.
Great. Kind of, you know, we talked, you know, you talked about HCA subsidies, and we just kind of don't know, but you're budgeting, you know, kind of for, you know, the scenario that if they do get extended or if they don't. Maybe.
We're preparing.
Oh, preparing.
Yes.
Yeah. I guess, you know, when we think about the kind of viewing the impacts of kind of how it might impact your beneficiary base, you know, when we think about 2025 guidance, is there an embedded view that, you know, you see more kind of that Medicaid returnation type of dynamic where utilization kind of spikes up as people, you know, get notified that, you know, their premiums are going to go up and likely exit the market?
I really can't talk about fourth quarter yet. When we look at third quarter, which would be the most current quarter that's public, we did not see any significant sign that demand had been pulled forward into third quarter on the exchanges related to people's concerns. You know, I think from the broad population perspective, you know, they're going to start experiencing this as they start going through the enrollment process. That open enrollment started November 1. You know, there's this kind of time period where people generally come in and start doing that work. We'll see. I mean, it's a legitimate question to ask, you know, would we have some pull forward in demand? We'll tell you on our fourth quarter call that we did not see any significant sign of that in third quarter.
Okay. Maybe just kind of focusing on, you know, the patients that you serve and kind of that's within the HCCS population, any kind of sense of, you know, kind of a conversion to CADE or commercial employer-sponsored or, you know, any kind of breakout in terms of where you think the, you know, beneficiary pool kind of breaks out if the enhanced subsidies aren't extended?
Yeah. If they expire, I think there will be a timeline where people start making adjustments. There will be a group of people we believe that will stay on the exchanges for sure because, you know, there are some people who need to stay on the exchanges. They need coverage, maybe people with chronic diseases and the like. They may drop a medal tier, but we think there will be, you know, a group of people who choose to stay on the exchanges in a pretty material way. For the ones that leave the exchanges, there are a group of people that we believe will go back to employee-sponsored insurance and are eligible for that. You know, I'm not going to size it for you. It's an estimate no matter who's predicting it.
Yes, I do think there's a component of people who will be able to go back to employee-sponsored insurance. Our view of it is that there will be no return to Medicaid. You know, to be eligible for the exchanges, you have to not be eligible for Medicaid. You know, I don't think people broadly are going to be going back to Medicaid as just a matter of the way the policies work or the way the structures work. There will be a group of people who become uninsured. You know, our view of that is that when people become uninsured, it's not like they quit using healthcare. It's just they just use ERs, emergency rooms. You know, I think there's a little bit less volume once someone loses coverage and becomes uninsured.
I think the access point changes to being really heavily weighted towards emergency rooms. It is not like they go from having coverage and using and demanding healthcare to no utilization overnight.
Maybe this maybe hasn't been framed like this, but I guess, you know, we've seen the expansive population increase in the, you know, the healthcare exchanges. But, you know, is it just a function of volume growth that it's, you know, because there's more people, there's more volume? Or is it, you know, the more chronic population portion of the exchanges are using their benefits more?
Yeah, it's an interesting question. Here's what I would say. The last couple of years would be illustrative of this in our view. In 2024 versus 2023, exchange enrollments in our states went up 30%. Our volume went up 40. You know, just to get a sense of we had 30% enrollment growth and 40% growth in volume. In this year, the enrollment went up about 13% and we're up about 10. There seems to be a correlation between enrollment and volume. Now, how much of that volume is coming from people with chronic diseases versus people who are covered but do not use it as much is a very difficult question. The way I see it is we have seen in the past good alignment between enrollment and volume. That's the way I would answer that.
Got it. You know, kind of going from the exchanges to a different payer, you know, looking at Medicare Advantage into next year, clearly a lot of, you know, significant changes on the, you know, around cost sharing and benefits as we look into plan year 2026. Perhaps too early to tell the impacts just given how AEP is trending and, you know, there's a difference between plan projections and what will actually happen from an enrollment perspective. Just kind of curious if, you know, there's been changes around utilization management, you know, kind of preceding, you know, this open enrollment period that will kind of continue into 2026.
I always like to start when I'm talking about Medicare at the macro view. You know, as we sit here today, about 58% of our total Medicare business is Medicare Advantage. The rest is traditional. When I look at 2025 and 2026, the number of people in America that are aging into the program is at a pretty high level when you compare it to the past 20 years. I think it's the function of the baby boomers retiring and the like are aging into the program. I do think next year you're going to see another year of pretty big overall enrollment growth in Medicare, at least compared to a 10 or 15-year trend and probably at least consistent with this year.
You know, there will be some movement, as there always is, but in 2026 there will be some movement between traditional and Medicare Advantage and within Medicare Advantage by payer as each payer kind of designs their benefit plans and sets their premiums and the like, they'll be moving through all that. Broadly, you know, I think our Medicare volumes should be pretty durable because of the overall enrollment growth that we're expecting. Within Medicare Advantage, I mean, our view in working with our payer partners is they've been pretty active at utilization management in the last several years, really active. You know, this idea of moving people from PPO to HMO or changing the utilization criteria, which if I were them, I would do too, right? I think there are going to be efforts there.
I think it's coming off of a pretty high baseline of utilization management that's already been in place. I'm viewing it as being maybe a little more incremental, but we're just going to have to wait and see. I don't think they're going from a scenario, though, where they had no utilization management to where they're going to have more utilization management. I think, you know, they're going to try to continue to improve their processes. I suspect it may be a little more incremental.
Yeah. Kind of speaking to one of the aspects of utilization management, just kind of pre-auths and, you know, denial of claims, you know, some of your peers have kind of called out an acceleration in that. We did not really see that for HCA in 3Q, just kind of still heightened, but not anything beyond the realm of what has been discussed over the course of the year. I guess, you know, I am curious on where HCA stands in terms of a denial rate relative to the industry and kind of how, you know, how you have kind of been able to drive that differentiation from a blocking and tackling perspective, especially as, you know, payers continue to, you know, comment on, you know, upcoding pressures from especially inpatient and outpatient settings.
These are two different things, right? Let me cover denials first. Over the last several years, we've seen the payers broadly, not just in Medicare Advantage, but, you know, broadly increase their activity levels around denials, their investments and their resources, their processes, their technologies and the like. You have seen it and we have seen it. HCA, given our scale and our ability to resource initiatives, we've been working really hard as a company in responding to that trend. The investments we've made in our contracting teams and efforts, the investments we've made in Paralon and our revenue cycle efforts have allowed us to respond to denials in a much more advanced way. I think that our response is what's creating a different outcome.
In other words, when I look at 2025 and I just kind of look at kind of concurrent denial levels, the new denials that come in, they're not slowing down. If anything, they continue to see more and more activity. I think our response is allowing us to manage that environment in a way to where it's not having an overall incremental net impact to the company. Now, it's having an impact, but not any more than last year. You have seen us say that like when we look at our net revenue per equivalent admission growth, that growth rate is not being impacted by denials because of our response. That is my thought process related to, you know, the denial trends. The activity level keeps going up. Our response keeps going up with it.
Great. Maybe speaking broadly to just kind of the aggregate mix on the rate side, clearly commercial employee sponsor is a larger book of business, but I think you do not really break it down by payer segment. You know, in the past, a couple of years, we have seen roughly 3%-5% kind of rate increases across the just aggregate payer base. You know, longer term, the algorithm for HCA is 2%-3%. Does that kind of, do we start seeing a normalization towards that as we kind of head into 2026 from a rate perspective?
Let's deconstruct that a little bit just for clarity. Our long-term plan on net revenue per equivalent admission growth is 2%-3%. When I think about our net revenue per unit growth, there are several drivers, right? You have the rate equation from both the payers and Medicare and Medicaid, yes. You also have payer mix. You also have acuity. Then you also have things like denials, underpayments, and the adjudication process. That 2%-3% growth in our long-term plan is the accumulation of all those drivers, not just rates. When I think about the payer rate environment, what we've said, you know, publicly is that we're about 80% contracted on the commercial book for 2026. We're still in our targeted rate range of kind of mid-single digits.
Yeah. I think maybe we should kind of break down the kind of that rate component that's related to, you know, some of the service line optimizations made because I think, you know, it kind of gets, you know, muddled up in the broader scheme of things as you, you know, try to drive more acuity or higher acuity caseloads. You know, that might not yield more volume, but it's kind of more on the rate side. I think kind of that balancing act, when we think about it, how much of that contribution on the rate perspective in terms of 2025 year to date has come in from the caseload optimization that you've done?
This year, we are pretty consistent on our case mix index. On the inpatient side, we measure this with case mix index for the most part. You know, our case mix index, I'll use third quarter, it was up about 30 basis points to prior year. We are pretty consistent. It has been pretty consistent, you know, kind of broadly across most of the major payer categories as well. Over time, the way HCA thinks about our service lines is part of our networks. We try to both deepen and broaden our service capabilities that we offer to patients in our networks with the idea that we want to be as comprehensive as we can and so that patients do not have to leave our system for complex care.
You have seen us over the last decade and you will continue to see us over the next decade both broaden our service lines. What does that mean? That means taking service lines and taking hub hospitals, but adding those capabilities in our feeder facilities as well, cath labs, open heart programs and the like. Then deepen our service lines where, and I'll use cardiology as an example, where we'll have kind of hub hospitals with really deep complex capabilities in things like structural heart and open heart and valve replacement and electrophysiology and the like. I think that work over time has allowed us to also increase the complexity of our revenue composition, especially over the last, you know, five or six years. As I think about into the future, that work of service line development will continue.
You know, I think it's a piece of the story on overall net revenue per unit growth.
Great. I think just maybe focusing on the policy, but instead of kind of HCA, let's think about kind of Medicare fee for service. By this point in time, we usually have the outpatient prospective payment system rule, but we still kind of haven't had that. One of the biggest items in that was the elimination or the drawdown of the or the phase out of the inpatient-only list over a three-year timeframe and, you know, largely focused around MSK procedures in year one and then kind of thereon and therefore. I guess, how have the conversations progressed, you know, during the comment period around the elimination of that? You know, clearly, you know, the physician fee schedule came out during the government shutdown, but it seems like the, you know, CMS might be doing some more legwork in the background before the final rule comes out.
Just curious on if there's a kind of ability or notion that, you know, CMS kind of treads back on that elimination of the inpatient-only list aspect of that rule.
We do not know yet, right? We will know when you know and when it becomes public. We have commented. You know, clearly we were disappointed in the proposal and not only just on the inpatient-only component, but also the acceleration of the 340B recruitment were the two components. Just a note though on the inpatient-only, this is traditional Medicare only. Within that, what it does is it tells physicians to use their judgment on where the patient needs care. For some of those cases, they very easily could continue to say that these patients need to be inpatient. Others may need to be outpatient. If they get rid of the inpatient-only list, it is not like all those counts automatically go to outpatient, right? It becomes the physician's judgment on what the patient needs instead of a rule.
Broadly, and especially when I think about next year, the inpatient rule was actually favorable to HCA Healthcare and more favorable than our past several years of updates. For our traditional Medicare book, 70% of the revenue is inpatient. For 2026, you know, the combined of the inpatient and outpatient rule, if it gets enacted as if it was proposed, which we hope it does not, but even if it does, we are going to still have an overall Medicare update that is equal to, maybe even a smidge better than the past several years. That is how we think about it broadly. We will just work through these components if they end up getting finalized into the bill.
Right. You know, on the Medicaid side and with the kind of one big beautiful bill, something that came out of it that's kind of beneficial for the industry is the, you know, the rural health transformation front. All 50 states applied for it. I know kind of when we think about HCA's network, you know, also, you know, housing the outreach networks, right, that may be eligible for these kind of funds under the program's criteria. Would you kind of frame that benefit being material if, you know, if there is kind of funding that is available to those outreach networks?
We think maybe 15% of our hospitals would be eligible in some way for potentially eligible, I guess I should say, for these funds, depending on how the applications get reviewed and approved by CMS. A lot of unknowns yet, you know, in terms of what they fund, what they do not fund. If you read through the applications on kind of the other half of the money, there is a lot of ideas in there beyond just handing money to hospitals. You know, it is a little too early to tell whether it will be how much of an impact it will be to HCA. Too early to judge. At the end of the day, it is still a good thing, right? It could be a potential upside for HCA depending on how that goes. A little early to size it yet.
I know I've been rambling for 30 minutes. I want to make sure if anyone in the audience had a question. All right. Great. As we kind of, you know, get towards the latter half of our conversation, maybe just want to focus on, you know, 2026 on a few broader topics, maybe starting, you know, with the development or, you know, potentially M&A pipeline under the new administration. There might be kind of more leeway on that front. You know, any update on the proof capital projects in the current pipeline and kind of how those investments pan out across the different asset types? I know you touched upon this on our kind of opening questions and remarks, but I think it would be helpful in terms of where some of the investments are being focused around.
Sure. On the capital investment side, it's always a mixture of inpatient and outpatient. We have been averaging about 600 beds a year of additions on the inpatient side through our capital investment program. I mean, that's kind of our program at this point. That will continue into 2027. I mean, 2026, sorry. You know, that's important to deal with hospitals that get into a high occupancy scenario so that, you know, we can make sure that we have the capacity to service the demand growth, take care of patients, say yes to transfers and the like. You know, we will continue on the inpatient side adding beds. Within our inpatient program as well, our acute care program as well, you know, we're making investments to expand hospital emergency rooms, operating rooms, cath labs, and the like.
All of that's also based on volume and occupancy and capacity. You know, inpatient projects tend to cost a little bit more than outpatient, a bit more, a lot more. You know, on the dollar standpoint, when you look at our growth capital, more of the dollars go on the inpatient side just because of the cost of those projects. We have a significant pipeline of outpatient development as well. You'll see a number of units getting added every year on the outpatient. Again, urgent care centers, freestanding emergency rooms, surgery centers, clinics. That work continues and it's in concert with that network development plan I walked through earlier. I think largely that idea of taking care of inpatient and expanding our outpatient facilities over time will be what you see from HCA on the capital investment side.
On the acquisition environment, you know, we're quizzed of now. The way I would say it though, it's been tilted a bit more to outpatient where there is a bit of more of a competitive market. In other words, these tend to be more for-profit private businesses that, you know, you can acquire. You know, we've had a number of acquisitions in the outpatient space over the last two years and we will always be looking to add outpatient capacity in our markets when attractive acquisition opportunities come up. On the inpatient side, you know, especially in network, you know, there's still FTC friction. I think that the current administration's FTC is better for private companies than under the Biden administration for sure, but there's still friction, right? You know, what we see more in our current markets are tuck-ins.
You know, we've done two this year. We bought a hospital in Manchester, New Hampshire that's part of our New Hampshire market and one in Florida in the Fort Myers area. You know, when we find opportunities in market, we still take them. The bigger the in-market competitor is, the harder the friction is. You just have to accept that and move through it. In terms of new markets, you know, we tend to be pretty disciplined in entering new markets. We've done it before and we'll do it again, but you've got to find a meaningful hospital system in the right kind of market for HCA that is for sale. We take a look at all of them that come available and, you know, the current policy environment may change the market a bit over time, but that's the way we think about it.
I think everyone appreciates this. HCA is a really disciplined allocator of capital. On the acquisition side, it's going to have to be the right market and the right asset for us to dive in.
You know, you've had this framing of kind of getting to 29% market share nationally by the end of the decade. How much of that contemplates just existing market or in-network kind of growth relative to just, you know, pursuing growth in new markets to achieve that target?
Yeah, it's tied to our existing markets.
Okay. Okay. Perfect. As we think about just some of the cost dynamics, you know, heading into 2026, I think, you know, one of the areas that have been persistent pressures in the industry is professional fees. HCA made kind of the investment of acquiring or wholly acquiring Velasco, which was priorly a joint venture outing. As we think about professional fees, one of your peers kind of called out September seeing heightened radiology pressure, which radiology seems to be more persistent than last year's anesthesiology. I think, are you kind of seeing that, you know, same type of pressure kind of hiking into 4Q or just kind of maybe broadly speaking? As we think about next year, is that rate of growth expected to moderate on your end as you continue to make more leeway on kind of your Velasco acquisition?
You know, Velasco was emergency room physicians and hospital medicine physicians. You know, we acquired that company and I'm really proud of that team. We are now not only stabilized that operation, but that's going really well. You know, all the work of our hospital management teams and our physician management teams and that group of physicians and staff have really produced a great outcome for HCA. I think we're in better shape now in those two service lines, emergency medicine and hospital medicine, to deal with not only the cost pressures in those areas. It's not like they're gone, but we can better manage them now, but also to create a strategic asset for the company.
Things like managing length of stay and managing operations for effectiveness and efficiency, we now have a home team that's really aligned with that vision. I think it's setting up the company well. The challenges really last year and this year are more in anesthesia and radiology. You know, as we sit here today through third quarter, our same facility professional fees have been up about double digits, about 10%, which was in line with our expectations as we started the year. It does represent those challenges. There are supply and demand challenges in both anesthesia and radiology in terms of providers and physicians.
We're still working through that and we're applying all the same kind of HCA strategies that you would think of, you know, in terms of the way we build and manage the vendor relationships, the way that we manage the allocation of these scarce resources and scheduling and performance in the hospitals and the like, including, you know, in anesthesia building our own internal capability where when we have to, we can employ anesthesiologists. We're working on these areas. I'm not seeing any expansion of the pressure, but I think, you know, as we go over the next, not only in 2026, but probably in the next two or three years, we're still going to be working through anesthesia and radiology pressures. It's the one area of our cost structure that is still a bit challenged.
Other specialties that you've kind of been more proactive on since you've seen these pressures in anesthesiology and radiology from a contract perspective that are kind of, you know, maybe being forecast or not forecasted, but being showcased in a 2025 P&O as you kind of become more proactive on that front.
I just would say that broadly, a lot of our growth in terms of this double-digit growth has come from anesthesia and radiology. Our work to manage emergency room, hospital medicine, and the like have allowed us to keep those growths in a little better control. You know, it's not like we're not working on it. I mean, 2026, we'll talk about what we think the marker will be in 2026 on our fourth quarter call, but I think it's still going to be a little more than just average inflation as we go into the future.
Great. Kind of now thinking about other cost pressures, just, or not cost pressures, but just cost items, just supply expenses, drug expenses, clearly, you know, economic policy have made those pricing fluid. You called out immaterial impacts from tariffs. As we think about kind of underlying growth trend for, you know, 2026 on that regard and kind of, you know, your majority stake in the GPO, how should we kind of think about the opportunities on the supply expense front? Clearly, it was a big portion of the investor day in terms of the incremental savings that the company can generate. Just kind of maybe any color on that front.
I think before I answer the operations question, you know, we have to acknowledge tariffs, right? I mean, we've worked really hard this year with HealthTrust and our GPO to manage the tariff environment the very best we can. I think that the work that they do to try to get longer-term fixed price contracts, the work that they do with our vendor partners to change sourcing and to change product selection and the like has added a lot of value to the company and helping us to navigate the tariff headwind. You know, I can't tell the future on tariffs yet, you know, because anytime I try to predict what's going to happen, then the next day of truth social comes out and I look like an idiot.
I'm going to stay away from yet trying to call what's going to happen on tariffs other than saying that I think HealthTrust has helped HCA do a really good job of navigating that challenge the best that we can and has put us in an overall pretty good spot. Broadly in supplies, and I think this year is a great evidence of this, we've been able to manage the inflationary pressures through our contracting and procurement processes in a way that coupled with our resiliency plans and how we manage things like new technology adoption and mix of products and the like, that we've been able to have a pretty good year this year on supply costs. I mean, we've had a bit of margin even improvement in supplies. I think that's a reflection of the work of the company.
That's not meaning that there's not inflationary pressure. There is. We work with our vendor partners to deal with that the best we can, but we couple that with the strength and the size of HealthTrust to help us manage that really well. Our resiliency plan has a number of initiatives pointed at supplies that will help us continue to find ways to be efficient in our supply management processes.
Great. I guess, you know, we're almost up on time, but maybe just. [crosstalk]
I'll mention this too because you haven't asked about digital. Supply chain is a great example of one of the administrative platforms that has the most opportunity from AI. If you just think about hundreds of thousands of SKUs with tens of thousands of vendors, supplies coming in from all over the world, you know, big data, data science, and building data products that help us manage that, not only the inventory loads, but the cost of the supplies are going to make a big difference over time.
Yep. Got it. Clearly, you know, AI is a very incremental tool even from a labor standpoint as well. That is kind of getting into the next question, just, you know, expectations for labor and wage trends heading into next year. Clearly, your investment in the Galen College of Nursing is very incremental to the future pipeline of acquisitions. Maybe just kind of talking around the conversion rate, you know, there is a philosophy of having, you know, a Galen College of Nursing in every HCA market. Where are we on that perspective and how that kind of is developing from a pipeline?
Yeah, it's a big part of our overall workforce development plan. Now, we also work with the legacy nursing schools too in very heavy partnerships. I mean, what Galen has allowed us to do is not only fix an HCA problem, but support our communities. The issue in most of the communities we serve is there's just not enough nursing schools, not enough spots for people who want to go to nursing school. It has clamped down on supply over the years. Galen opens up all these new nursing school spots for people who want to become nurses. In our markets, you know, when we acquired Galen, there were four campuses in 2021. As we sit here today, there's 20. I think it's 21. As we go between now and 2030, we'll be at about 30.
Thirty of our 43 markets will, you know, roughly have a nursing school. Some of those markets will have two. You know, we believe by the end of the decade, we'll have about 30,000 students in Galen and probably 8,000-9,000 annual graduates. It has been a really good program for HCA and the communities we operate in to build this better supply of nurses in our markets. We're real proud of those teams. They've done a great job.
Perfect. I think that puts us up on time and that wraps us up. I want to thank the HCA team for joining us here today.
Thank you. All right. Thanks, everybody. Good to see you.