Greetings, and welcome to the Surgery Partners third quarter 2019 earnings conference call. At this time, all participants are in listen-only mode. A brief question-and-answer session will follow the formal presentation. If anyone should require operator assistance during the conference, please press star zero on your telephone keypad. As a reminder, this conference is being recorded. It is now my pleasure to introduce your host, Tom Cowhey, Chief Financial Officer. Thank you, sir. You may begin.
Good morning, and welcome to Surgery Partners' third quarter 2019 earnings call. This is Tom Cowhey, Chief Financial Officer. Joining me today is Wayne S. DeVeydt, our Chief Executive Officer, and Eric Evans, our Chief Operating Officer. As a reminder, during this call, we will make forward-looking statements. Risk factors that may impact those statements and could cause actual future results to differ materially from currently projected results are described in this morning's press release and the reports we file with the SEC. The company does not undertake any duty to update such forward-looking statements. Additionally, during today's call, the company will discuss certain non-GAAP measures which we believe can be useful in evaluating our performance. The presentation of this additional information should not be considered in isolation or as a substitute for results prepared in accordance with GAAP.
A reconciliation of these measures can be found on our earnings release, which is posted on our website at surgerypartners.com, and in our most recent interim report on Form 10-Q when filed. With that, I'll turn the call over to Wayne. Wayne?
Good morning. Thank you, Tom, and thank you all for joining us today. For our call this morning, I will review some highlights from our third quarter results and then provide an update on several of our strategic initiatives that support our organic growth and margin expansion, and briefly discuss how those initiatives impact our sustainable double-digit adjusted EBITDA growth goals. Finally, I'll turn the call over to Tom to provide further details on the quarter. Starting with the quarter, I'm pleased to report third quarter 2019 adjusted revenues of $458.3 million and adjusted EBITDA of $62.2 million. As we look deeper into the quarter, adjusted EBITDA grew by 5.4% over the third quarter of 2018, consistent with our previous guidance and our targeted double-digit full-year growth. Days adjusted same-facility revenue increased by 7.9% from the prior year quarter, driven by strong net revenue per case and volume growth.
We are pleased with the significant growth over the prior year, representing our fifth consecutive quarter of same-facility revenue and case volume growth, which we believe is a testament to our efforts. Finally, adjusted EBITDA margins were 13.6%, an improvement of 30 basis points over the prior year quarter. As Tom will discuss later, adjusting for the impact of closed or divested facilities, revenue growth would've been over 9%, and EBITDA growth would've been approximately 13% over the prior quarter. Our strong third quarter performance does not incorporate any add-back or adjustment for the impact of Hurricane Dorian in early September, which we estimate reduced our reported results by over $3 million in revenue and approximately $1.2 million-$1.5 million in adjusted EBITDA.
While our facilities fared well in the storm, to ensure the safety of our employees and patients, 14 of our facilities along the southeastern coast closed for anywhere from one to four days, representing over 750 previously scheduled surgical cases, many of which were higher acuity. It is our hope that we can recapture some of this lost volume by the end of the calendar year. As we prepare for the fourth quarter, we continue to be pleased with our year-to-date progress on a variety of fronts. Same-facility revenues continue to exceed the high end of our targeted long-term range of 4%-6%. These results are driven by both our physician recruiting efforts as well as solid improvements in our commercial rates.
More importantly, as we discussed on our previous call, there is a compounding impact on our business as new surgeons continue to ramp up in our facilities, while we are concurrently improving our commercial rates, a compounding that we expect to meaningfully impact our fourth quarter 2019 and longer-term results. A few data points to anchor on. On a year-to-date basis, same-facility revenues are up 7.6%, an improvement of 300 basis points over the comparable period in 2018. During this period, the contribution margin from our physicians recruited since the beginning of 2018 are already more than double their contribution from all of 2018, and we expect to see further strength in the fourth quarter consistent with typical industry trends for our sector. Our 2019 physician recruitment cohort is also driving strong results.
To date, we've recruited an equivalent number of doctors at this point last year, and those doctors are performing cases at a 25% higher direct contribution margin per case versus last year. Finally, our data-driven focus to grow in our targeted specialties, including our total joints programs, has yielded meaningful improvements in higher acuity cases. Year to date, we've done approximately 800 total joints in our ambulatory surgery centers, which is double our total at this point last year. As you can see by our results, we continue to be pleased with our team's efforts in making our surgical facilities a destination of choice for both physicians and patients. We are equally pleased with the positive momentum we continue to make with payers in sharing with them the experience their members can enjoy at a much more affordable and efficient facility.
A testament to our efforts relates to our recently completed off-cycle rate negotiations in a few pilot markets where we achieved double-digit commercial increases that commenced early in the fourth quarter of 2019. These negotiations were successful due to the demonstrable value proposition we provide state, regional, and national health plans. Our health plan partners increasingly understand and value the benefits that a vibrant, independent, short-stay surgical facility operator can provide to them and their members. We look forward to continuing and are already actively engaged in this dialogue with other payers across the country. As we start to look to next year, we are confident we can continue to build on the strong foundation we constructed over the last seven quarters. Our model remains the same.
We believe that our base business can grow at 2%-3% on volume and 2%-3% on rate, yielding 4%-6% same-facility revenue growth with a bias towards the higher end of the range. Our results to date are proof that if we focus on bringing the right doctors, doing the right procedures in our targeted specialties, and focus on getting appropriate payment for the value we bring to the system, we can achieve at least this level of growth. On top of this baseline for growth, we've been focused on three additional areas to expand margins that we expect will contribute an additional 3%-5% of growth in support of our double-digit adjusted EBITDA growth goals. These areas include procurement, revenue cycle, and G&A leverage.
We continue to plant seeds in each of these areas, we are confident they will bear further fruit in 2020 and beyond. We have built new leadership teams in these functions over the past 18 months that continue to scale these initiatives, we see broad opportunities. In procurement, as we continue to optimize our GPO contract, we are also making progress in negotiating purchase discounts on implants and other supplies, as well as being more creative in how we purchase to take advantage of rebate opportunities. On revenue cycle, our centralized operations are starting to exceed our collection targets, we're using new data from consolidation of electronic claims submissions to begin to optimize denials management across wide portions of our business. As many of you know from your previous experience with several members of this management team, we have a maniacal focus on G&A management.
We have just recently implemented new tools and policies to further monitor and manage our costs. These distinct initiatives, on top of our base growth, give us confidence in our double-digit trajectory. Finally, as we look beyond the tactical, our Idaho Falls Community Hospital is slated to open its doors just days from now. This multi-year investment in a new acute care hospital will complement our existing surgical hospital and expand our capabilities in this very important market for our company. We are excited to be able to better serve this community with a brand-new facility, and we expect this to be a material contributor to our adjusted EBITDA in years to come. More broadly, our Idaho Falls effort demonstrates our willingness to make strategic investments across our portfolio to achieve long-term, sustainable, accelerated growth.
We are building Surgery Partners every day to be positioned consistently and predictably achieve near-term, medium-term, and long-term growth goals. Before I turn the call over to Tom, I'd like to spend a moment on Friday's announcement from CMS regarding the calendar year 2020 Medicare Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System final rule. We were pleased with the announcement across a variety of fronts as we felt CMS demonstrated their commitment to ASCs. With respect to overall rates, CMS has finalized an aggregate rate increase in 2020 of 2.6%, which is 50 basis points higher than the 2019 aggregate rate increase. While the specific rate sales will impact individual ASCs in different ways, we are pleased by CMS's continuing commitment to the ASC industry.
Another exciting development for 2020 is that total knees and six additional coronary intervention procedures were added to the Medicare ASC Covered Procedures List for the first time, opening up vast new markets for our facilities. Finally, total hip replacements, six spinal surgical procedures, and certain anesthesia services were removed from the Medicare Inpatient-Only List, making these procedures eligible to be paid by Medicare in the hospital outpatient setting, in addition to the hospital inpatient setting in 2020. As with total knees, which was first removed from the Inpatient-Only List in 2018, we believe this move could signal additional near-term and long-term opportunities for our facilities to better serve the Medicare population. The continued favorable actions undertaken by CMS to benefit ASCs demonstrates what we know to be true. Our industry in general, and Surgery Partners in particular, is on the right side of quality and cost-effective healthcare delivery.
Government regulation continues to reflect this. With that, let me hand the call back over to Tom for an overview of our third quarter financial results and 2019 outlook. Tom?
Thank you, Wayne. Today, I'll spend a few minutes on our third quarter 2019 financial performance, starting with some of our key revenue drivers, then moving on to adjusted EBITDA, cash flows, and our 2019 outlook. Starting with the top line, surgical cases were just shy of 130,000 in the quarter, up 2.1% from the prior year period, despite the loss of cases from closed or divested facilities that contributed nearly 3,300 cases in the prior year quarter, and the impact of Hurricane Dorian, which we estimate impacted us by just over 750 cases in the current year quarter.
We ended the third quarter with approximately $458.3 million in adjusted revenue, up 3.2% as compared to the prior year quarter, despite overcoming $25 million of revenue in the prior year quarter from closed or divested facilities and over $3 million of estimated lost revenue from Hurricane Dorian in the current period. On a same-facility basis, days-adjusted total company surgical revenues were up 7.9% from the prior year quarter, driven primarily by net revenue per case, but also by higher same-facility volumes. Turning to operating earnings, our third quarter 2019 adjusted EBITDA was $62.2 million, a 5.4% increase over the comparable period in 2018. Of note, closed or divested facilities contributed just under $4 million of adjusted EBITDA in the prior year quarter, and we estimate that the marginal adjusted EBITDA impact from Hurricane Dorian in the current period is between $1.2 million and $1.5 million.
Our third quarter result is consistent with our expected quarterly cadence despite the hurricane impact, and continues to position us well to achieve full year double-digit adjusted EBITDA growth. During the quarter, we recorded approximately $5.3 million of transaction integration and acquisition costs, bringing our year-to-date total to $16.8 million, less than half of our year-to-date 2018 costs, and consistent with our guidance that integration related costs would subside. Of note, third quarter 2019 transaction integration and acquisition costs included approximately $1.4 million of costs associated with our de novo hospital in Idaho Falls. We expect to continue to record these costs outside of adjusted EBITDA for the remainder of 2019 and throughout 2020.
While net revenues in our ancillary and optical segments were down slightly on a combined basis versus the prior year period, combined adjusted EBITDA from these two segments was relatively stable versus the prior year quarter, and consistent with our previous comments about our outlook for these businesses. Moving on to cash flow and liquidity. An important part of our strategy is to optimize our cash flow to be able to deploy available capital and generate returns for our shareholders. We continue to evaluate our portfolio to ensure that we are the best owner for our assets as we scour the landscape for organic and inorganic investment opportunities to drive future growth. I'm particularly pleased with the efforts of our treasury and development teams, whose efforts have once again been a highlight this quarter.
At the end of the third quarter, the company had cash balances of approximately $111 million. A revolving credit facility remains undrawn, with approximately $115 million of availability. Of note, during the third quarter, Surgery Partners had net operating cash inflows, defined as operating cash flow less distributions to non-controlling interests of $28.3 million. We deployed approximately $8 million in cash, that is accounted for in various sections of the cash flow statement, related to a buyup and related investment in an existing facility in Montana. We used approximately $13.3 million for payments on our long-term debt. The ratio of total net debt to EBITDA at the end of the third quarter of 2019, as calculated under the company's credit agreement, decreased to approximately 7.6 x, as a result of higher trailing 12-month adjusted EBITDA and greater visibility into the value of some of our managed care initiatives.
As we have noted before, the company has an appropriately flexible capital structure with no financial covenant on the term loan or our senior unsecured notes. We continue to project that the company's total net debt to EBITDA ratio should naturally decline over time as our business continues to grow, but may fluctuate on a quarterly basis based on timing of cash flows. With respect to our capital structure and leverage calculation, we expect that financing leases will increase by approximately $105 million in the fourth quarter as we take possession of our new facility in Idaho Falls, and we project that our new community hospital will also incur nearly $30 million of new local debt to finance equipment needs.
Consistent with the terms of our credit agreement, we expect to begin to incorporate the long-term EBITDA contribution from this facility in our credit agreement EBITDA in the fourth quarter, which we believe could be between $20 million-$30 million annually when run rate is achieved over the next few years. Given the magnitude of this adjustment, we wanted to start to socialize the deleveraging impact of this adjustment with investors now. Before we move on, I'd like to take a moment to discuss the investment we made this quarter in our surgical hospital in Montana, including purchasing the remaining interest in an associated ASC and the local clinic. This non-traditional opportunity, first identified by our local teams, allows us to fully deploy some of the strategic resources we have built in revenue cycle and managed care, unlocking a myriad of revenue and cost synergies over time.
This unique investment in an existing market will better position Surgery Partners to grow in this geography and better serve the local community, and we are truly excited by the long-term potential of this market. Moving on to our 2019 outlook, we are excited by our progress this quarter on a variety of fronts and remain committed to double-digit adjusted EBITDA growth this year and our full year revenue guidance of low single digit growth or high single digit growth, excluding divested revenues from the 2018 baseline. As we look forward to the fourth quarter, which is seasonally our largest earnings quarter, we would ask investors to keep in mind the following trends. Higher deductibles have continued to push commercial procedures to later points in the year. To date, our government business mix is approximately 140 basis points higher than the same period last year.
We continue to expect commercial business mix to improve in the fourth quarter, which should drive higher net revenue and profit per case. The value of some of our strategic initiatives, including the savings from our health plan consolidation, are backend weighted. The two surgical hospitals we closed late in 2018 were negative contributors to adjusted EBITDA in the fourth quarter of 2018. Those losses will not recur this year. We have newly negotiated rates that are currently in effect in several key markets. While the seasonal nature of our business always introduces late year risk, we believe we are well positioned to achieve our full year guidance. In summary, we believe our year-to-date 2019 results continue to demonstrate our ability to achieve our targets. We are pleased to see strong same-facility revenue growth with continued margin expansion as our initiatives take hold.
We continue to invest to expand existing facilities and enter new markets that will support organic growth as we finalize preparations for new Medicare procedures in our facilities starting in 2020. With that, we will open the call for Q&A. Operator?
Thank you. We will now be conducting a question and answer session. If you would like to ask a question, please press star one on your telephone keypad. A confirmation tone will indicate your line is in the question queue. You may press star two if you would like to remove your question from the queue. For participants using speaker equipment, it may be necessary to pick up your handset before pressing the star keys. One moment please while we poll for questions. Thank you. Our first question comes from the line of Kevin Fischbeck with Bank of America Merrill Lynch. Please proceed with your question.
Great, thanks. Wayne, I heard the comment, but I guess I wasn't sure exactly what the context was. You said that you guys are reiterating your 4% - 6% same-store revenue growth expectation, and you said that there's a bias to the high end of that. Was that just really for 2019, or were you saying that for the next couple of years you think you can be towards the high end of that range?
Hey, Kevin. Good morning. Short answer is not just for the current year, we think really for the next several years that we should be at the high end of that range. I think as we continue to go deeper and see the volume compounding effect of our recruiting efforts, coupled with the fact that I think our opportunities on rates are probably much more meaningful than the typical 2%-3% on rate that you should get. I would say the bias is towards the high end of that range.
When you think about that rate dynamic part of it, how much of it is on this commercial recontracting versus some of the acuity mix shift that you talked about as well?
I would say first and foremost, a substantial part of it is just getting the rates that we're entitled to in the markets. We still have several markets that are well below what our appropriate level, what we would say even being at the average of average rates. Since we've been able to bring on the full-time managed care team, and as I mentioned in the prepared remarks, we've had several programs where we've done off-cycle increases that have been in the double-digit range. I think we're getting more and more momentum there. That being said, mix does play a factor in that. I would say mix would be the factors that could put us above that high end of that range, above 6%.
I would say just purely on the typical rate negotiation of 2%-3% that you should get on rate, we should be able to exceed or at least be at the high end of that and then let mix be the delta.
Okay.
Hey, Kevin, it's Tom. Good morning. It's a compounding effect as well, especially as you think about how our physician partners are able to share in the economics of the facility through their ownership. As we achieve more attractive rates, it actually incents them to bring more procedures to our facilities.
Yeah. I guess maybe just to build on that, this ramp that you've been able to do over the last couple of years as far as physician recruiting and then their ramp up as they come on board, how much more do we have to go before you anniversary all of that and get to the point where it's now steady state versus this big ramp? Do we have another year of this next year, or is next year going to normalize into the long-term sustainable growth trajectory?
Let me first start by saying, as we've done our own internal 5-year projections and shared them with our board, there is no reason to believe that we should not be able to achieve the higher end of that range for both the near and the longer term. I don't think that we're going to hit an inflection point for at least two to three years out at best, if not longer, simply because I think the opportunity is meaningful. I would add to that with the shifts we're seeing with CMS, the new procedures that will come in our procedures, it's going to open up a whole new avenue for us to leverage our fixed costs that we have there today.
If I look at pure, ignore even the transition and the new opportunity that's afforded to us with CMS rules that were finalized on Friday, I would say, Kevin, I think we've got three to five years of positive runway at the high end of that range or better.
All right, great. Thanks.
Our next question comes from the line of Ralph Giacobbe with Citigroup. Please proceed with your question.
Thanks. Good morning. Just wanted to understand the improvement of the commercial rates beginning in the fourth quarter. Can you give us any sense at all of what percentage of the commercial book will see the boost? I certainly understand the value you guys bring, but just help us on the premise of the payers giving you the off-cycle bumps. Where are you in that process? I guess for those that don't give you those off-cycle increases, how long to get through the book to get to that higher baseline?
Yeah. Let me first start with just strategically, why would a payer give us an off-cycle increase? I think that's the most logical question. One of the things that I would tell you, Ralph, is as we've been meeting with the payers, we've gone to them with them understanding that it is our preference and it is our playbook to be the value play in a market, to have the quality that we offer at our facilities coupled with the value play. What we do now is share with them the data that shows where we think the value play should be at versus what we're being compensated at, and what alternatives are available to us in the market if the payer chooses not to want to participate in that value play.
Said differently, it's always our preference, as we've said, to first partner with a payer on the right market structure. If that's not available to us, we know there's many providers out there and health systems that would like to partner with us as well. We continue to try to partner with those that look at being a value play in the market. Under any scenario, our rates go up. I will tell you pretty much across the board as we look at our book and as we're going through these negotiations, we can either partner with a health system and have meaningful rate increases, or we can partner with a payer and have meaningful rate increases. As I said, it is our goal, it is our mission to be the value play in a market.
We're not necessarily looking for what just drives the greatest EBITDA. We're looking for what accomplishes a longer sustainable business model goal. If a payer, in this case, a payer would not want to participate, then we are going to partner with a health system to get the rates we believe we're entitled to in a market. I would tell you is, while we won't size up necessarily for you what percentage it is of commercial, what I will tell you is it was nine of our facilities, reasonable contributors to our EBITDA in Q4, all getting a double-digit increase across the board. This initiative, just so you know, started early in the year. These were things we thought would happen when they would happen, so we're very pleased with that.
We have inflationary kickers over the next several years that are meaningful. I feel like this was the starting point of starting to leverage our value prop and leverage the idea of providers being in the market. The other thing, though, is I'm going to let Eric just comment on, since he's been here, and he really brings, as you know, a lot of surgical facility and surgical hospital experience. One of the things that he's been doing in the managed care sector is really looking at just even basic things available to us, for example, under the chargemaster, and whether or not we've been taking advantage of those opportunities that are afforded us in our facilities. Eric, maybe comment on some of your work there as well and how that will start benefiting us in Q4 as well and beyond.
Sure. Good morning, Ralph. Just to build on Wayne's points, one thing I would also say just on the payer side is we do take a very much a collaborative approach. As we think about any rate increase, the reality of it is most of the time that's going to be in a situation that makes our facilities more attractive and actually draws patients potentially from higher cost settings, right? The goal here is, in total, another reason a payer would do something off cycle with us is the opportunity to make us more sustainable in the market to actually draw procedures over to what are higher value settings, even with a rate increase. We look for win-wins there clearly.
To Wayne's point, from a facility standpoint, as we've grown the company, we have not been probably as disciplined as we could be around just thinking about annual rate increases, how we should think about managing our book based on where we sit in a given market. We've got some opportunities there as well that we're looking at to be more consistent and to make sure that we are appropriately adjusting our charges to reflect market realities and where we sit. All of that said, I think what's great is even in these conversations where we are having discussions with payers that maybe are a bit out of cycle, the reality of it is for these payers, we present enough value creation that they want to make investments in us, right?
They want to make investments in us as an alternative in some markets, and they want to make an investment in us because of our quality and service. We feel good about we're part of the solution, and we want to make sure that while we offer a discount, we don't offer a deep discount that is unwarranted.
Okay. That's very helpful. I wanted to sort of switch topics, but somewhat related. You guys noted the CMS announcement of knee replacement and certain cardiac procedures moving to ASCs. Is there any way to frame the opportunity or give us some guardrails around what you think the opportunities are? We've certainly had payers, namely United and Anthem, sort of push changes to benefit design around site of service and prior auth. Can you give us a sense of either maybe what your overlap with those payers are in your markets, and how meaningful or not of a driver do you see it specifically for 2020? Thanks.
Ralph , appreciate the question. Let me start by saying I think both are very meaningful trends for our industry and our business model specifically. Look, let me start with the payers. This is well overdue. I think enough quality data has been supported now that shows that the quality is actually, in many cases, equal or better than what you get in acute care hospital settings. I would also add that nobody will debate or dispute that there's generally a 45% lower cost structure for it. I would say that the payers and the moves they're making, and I would tell you there's meaningful overlap in our markets with those two payers you mentioned, as well as other payers that are considering similar processes.
On top of that, relative to skating where the puck's going, we didn't spend much time this past year highlighting the idea that we were fairly bullish this would happen, but we knew that you never quite know if this gets delayed another year. In terms of sizing it, I don't want to get ahead of our board, but we actually have board meetings this week, and that's part of what we're going to be sharing with our board is a little bit of our thoughts on this space. What I would tell you is we've spent the last year expanding multiple location ORs for exactly this opportunity. As you know, OR expansions are fairly inexpensive to do if you're simply adding on a room to an existing facility.
I would also tell you on our physician recruiting efforts, we've spent a fair amount of time this past year starting to build deeper relationships with those physicians in markets that we believe our facilities are not only capable of bringing on this new windfall that's coming our way, but more importantly, with the quality physicians we want to do it with. While I won't give specific names, we have physicians that are doing anywhere from 500 to 1,000 total joint procedures a year, which gives you an idea, but mostly in Medicare and generally in high retirement communities, but areas that we are actually well-positioned. We're going to continue to have those relationships, and we're looking at syndicating.
More to come, but what I would tell you is I just view these as additional tools in the toolbox that should give us confidence in our long-term double-digit growth.
Okay. Very helpful. Thank you.
Hey, Ralph, I'm going to pile on even though I know you probably just dropped off. The only other thing that I just want to highlight for you is this is part of the reason that we've been trying to demonstrate for you the number of procedures that we're already doing of this type in our ASCs. We're doing these types of procedures today for our commercial clients, and we have the capabilities and are actually doing this in about a third of our ASCs today, and have capability to do it more than that. We think we're really well-positioned for this opportunity over the short term and over the longer term.
Okay. Thank you.
Our next question comes from the line of Chad Vanacore with Stifel. Please proceed with your question.
Hey, good morning, Wayne and Tom.
Morning.
Hey, Chad.
I would like to continue with Ralph's question on the opportunity in knees and maybe even hips. If you can't quantify an initial impact in 2020, where do you think you can get to in five years? If you'd rather, how much of that business do you think migrates from inpatient to outpatient?
A difficult question to answer, not because we don't want to answer, but because I think ultimately some of these projections we're going to be sharing with our board. I will tell you it is our intention to share these early next year with you on a 5-year outlook, and we'll give more detail. Let me give maybe some anecdotal things that hopefully will be somewhat helpful in answering it. For 2020, it's a little more challenging simply because we've been working with a number of physicians that we would like to start having move procedures into our facilities, but ultimately, they couldn't until this rule went into effect. What I would tell you is we've got a lot of physicians lined up.
We have a lot of individuals that we're wanting to commit, but the reality was, until Friday, we will now know for certain how strong that commitment is and whether we'll actually get those individuals to syndicate and move forward with us. Until I can really see how that enrollment comes along, we'll have to see where that's at. The other thing to keep in mind is that some patients are, of course, you know, never really candidates. I mean, they have to remain in an inpatient setting. One of the things we have to look at, too, as we've been targeting certain surgeons and physicians, is we're trying to target those that we believe have at least more of a bias to what they could do in an outpatient setting.
Again, a lot of moving parts, but I think 2020 is a slower ramp-up, to be honest, just because we're now late in the year. A lot of these docs we've been recruiting now. Now it's going to be full push to go back out and say, "Look, the rules are there. Can we get you to start scheduling time?" If you just take physician recruiting in general, and I don't think these patterns would be any different with our Medicare doctors. Last year, we added almost 500. This year, we think we'll add about 500 new surgeons as the year progresses. When you look at those numbers, generally the pattern is those physicians will do one or two procedures for the first two or three months in your facility, simply to see, can you deliver on your promise, right?
If you do, they start to do three to five the next month, and four to five, and then eventually you're getting them to do 25 procedures a month. I want you to know that ramp-up time is it takes really a full digestive year from soup to nuts. I think it will be slow out of the gate in 2020, but ramp up by the end of 2020. I think 2021 is when you really start to see more run rate sustainable movement at that. Remember, we're going after a new physician base that a lot of them that do purely Medicare, that we're trying to get moved into this population. More to come, but in general, I'm just very bullish that this just, to me, I just view it as another example of why we should have confidence in double-digit growth.
I wouldn't necessarily start adding to it, because as you know, there's many levers you pull at different times. We think the opportunity is very meaningful.
All right. I'm going to ask you an even more granular question on the general topic, which is, presumably, most hip and knee replacements are Medicare-covered. Have you thought about how that impacts government pay mix?
This is Eric. Certainly, yes, there's a fair amount of those that are Medicare-covered, and clearly we are very focused on looking at implant costs and making sure that we appropriately prepare for what that reimbursement looks like, because it will put pressure on margins. The good news is that acuity growth, when you think about just the revenue opportunity for us, is pretty meaningful in the ASC setting. We've got a lot of efforts underway. We do feel confident we can make that a creative business, but it's going to take some work. Clearly, we have to earn some commercial mix with that. The idea here is that a lot of these surgeons, they have a fair mix and our job is to earn all that business and make it all make sense in total.
We believe through our efforts, particularly as we gain volume and as we really go deep on how we deal with physician preference items and the type of deals that we get with our vendors for implants, we see it as a tremendous opportunity. You're right, with something you got to prepare for and be very precise on how you manage your costs.
A reminder, while lower margin business, it's a very strong return on invested capital. From our perspective, this is still very good business, very positive EBITDA cash flow growth. It'll put some pressure on margins, I would tell you, even with that, we still expect margin expansion over the next five years.
Absolutely
Consistently every year.
All right. I just want to get to you on the rate renegotiations fourth quarter. Did I hear that right? You got double-digit rates compared to, say, your target of 2%-3%? Why such a large rate increase?
The first answer is yes, that you did hear it correctly. Two is, look, it really came down to the value play in a market. I think as Eric said, the data has always been readily available, and I think as a management team, hopefully we'll continue to prove to you and our investors that we're very data-driven in all of our decision-making. As we went out with the data, we simply met with the payers to show them where we know the market was bearing relative to rates for procedures being done in an outpatient setting. We have health system data that we can get. We can get other ASC. This data is available, and as you go out and pull this data, even if it's sanitized, you can understand where you stand in the pecking order.
Part of it has been simply us going out saying, "We've been an underpaid facility for many years. We believe we add meaningful value." We show them our ability to create steerage over time through our programs and our quality programs. We basically show them the alternative, which is if we can't get paid meaningful rates to maintain and grow a sustainable business model in certain markets, then we'll partner with health systems that will also give us those sustainable rates. I think the key is we have health systems that see all the trends happening. Their procedures are moving into an outpatient setting, and many of them are not prepared for this. We have payers who would prefer to see those costs go to where we're at in value play, then move to a health system cost structure.
We just happen to be uniquely positioned in the right space at the right time to have two very leverageable points, and we're going to continue to use those in every market we're in.
One thing I might just add onto that, when you think about managed care side, we're taking a more of a state, regional, and national approach. One of the problems when you're just simply individual facility negotiations that we've missed is kind of telling the broader story of the value we can create in a given market or state region. That is a different approach for us, and I do think that as payers realize our scale in certain markets and our ability to actually meaningfully help them more than just one location, but across the geography, that also changes the story. It changes the place we're negotiating on, right?
Not just about a local unit cost, but about how in the course of a repayment over a broader geography can we help drive costs down in the system and help them create value. I think that's positioning us well as we move forward.
All right. I'm going to sneak in one more question. By maintaining double-digit growth outlook for FY 2019, there's implied steep ramp above what would be typical seasonal strength in four Q. How much of that ramp do you expect to be driven by revenue increase, and how much is that from margin improvement?
Appreciate the question. Just some high-level things to keep in mind. As we benefited from some of those divested assets in Q3 in the sense that they had EBITDA last year, of course, that's not here this year. Those assets were very lumpy in their seasonality, some of our divestitures actually lost money in Q4. Let me just start by saying that there's several million dollar pickups simply by not having losses recur in Q4, which probably gives you a little more of a sense that the seasonality patterns are not as far off as what historically you've seen if you just adjust for that. I would tell you that it's probably heavier on the revenue side.
Pretty meaningful lift that we have coming, both through the rate negotiations plus the ramp-up of doctors that we've seen from not only 2018, but all those hired in 2019. Those patterns historically, as I mentioned earlier, the seasonality of how a doctor gets engaged with your facilities usually gets pretty meaningful in Q4. Q4 is typically heavy commercial. Many physicians are generally somewhat intentional in how they schedule their procedures around Q4. I would say it's heavier weighted towards that. That being said, we have value benefits coming through, we expect from our benefit design changes we made in our health plans and more G&A leverage, and the RCM benefits continue to look positive each day. I think you'll see both margin improvement, but I think you'll see strong top line.
All right. That's it for me. Thanks.
Thanks, Chad.
Our next question comes from the line of Brian Tanquilut with Jefferies. Please proceed with your question.
Hey, good morning, guys. I guess my first question, just to follow up on Chad's last question. As I think about Q4, is there anything qualitatively, at least, you can share with us in terms of what you're seeing in terms maybe with volume shifting from Q3 because of Dorian? How should we feel comfortable or confident with the revenue ramps that you're expecting, just like you alluded to?
Brian, let me start by saying that, again, I think due to the one-time items that were there last year, coupled with many of our initiatives that were fourth quarter loaded for the benefits that we expected, obviously we have insights that you're trying to get comfortable with. That being said, when Hurricane Dorian happens, as you know, it's a day that you lose. You just don't ever recover those days back to scheduled procedures. The hope is that you'll get some of those rescheduled into the fourth quarter. What I would say is October seems to be at least indicating that that has happened. We're not done closing our books. We have a view on case volume.
I would say all those facilities that were affected appear to be performing well in October, and generally very strong versus our original expectations when we built our budget. I think as of today, we feel pretty good on the volume. I think the biggest thing is really comes down to mix and does the mix shift like in commercial we've historically seen occur, especially because we know we have pretty meaningful rate lift across the board in our commercial book in the quarter. I think it's going to be a more to come, but I would say our commitment to double-digit growth is still there, and we have many levers that we could pull if we felt there was any pressure in the quarter.
I appreciate that comment. Wayne, as I think about, just shifting gears to the whole total knee replacement opportunity, obviously one of the key debates is what is the right reimbursement, right? This is kind of a new area for a lot of the payers as well. You mentioned 45% cheaper than hospitals is what you guys are averaging at as an ASC industry. Is that the starting point of the conversation as we think about the economics of total knee replacements?
First of all, if you look at what they've proposed, I think it's $8,000.
Just north of $8,000.
Just north of $8,000 is what they've proposed. We've looked at a number of our facilities and believe we can earn a reasonable return on that. Now, keep in mind, I think this is what typically happens with all government business. Everybody cries foul and says they can't make money in this environment, as we've heard for years on Medicaid and Medicare, and then somehow the industry becomes innovative and figures it out. I would just simply tell you that in a lot of ways, we actually welcome this stake in the ground at these rates. Would we like to be paid more? Of course, we would, but I would tell you our business model was built to be efficient like this. Because of our fixed cost leverage structure, we think we'll be just fine.
The core issue's going to be how do we continue to manage our contracts around our implant costs and what we're doing there, and that's where Eric and the procurement team have a pretty substantial effort that gives us confidence that we can do well in that environment. If we're not able to in a particular market or particular facility, remember, we lose nothing from this. This is only upside to us. I feel like we're in the right spot at the right time, and we've got a lot of optionality on how we want to play. Eric, anything you want to add?
Yeah. The only thing I would add there, Brian, is that I think what's interesting. Medicare obviously is typically one of the lower payers. When we talk to commercial payers, what we really spend our time focusing on is the gap between what they pay today and what they could pay in our facilities, and the value creation is pretty large. It's interesting. As payers are starting to look at this, they're realizing that, hey, they're probably making an investment on the ASC side to pay a better rate that helps make sure we cover the implant, that helps attract docs to the outpatient setting. Making those investments is still a huge win for them.
We expect, yes, while there's some pressure on the Medicare side, and I think it'll play out over time whether the rate they have is sustainable and actually moves enough business because what they really want to do is take advantage of that huge gap, right? Whether they go to $8,600 or eventually $10,000 or whatever that number is, their savings is large. They're trying to find that spot. I will tell you on the payer side, they see that large opportunity as well, and it's our job to make sure we get paid fairly and capture some of the value that we can create. We see it as a huge win. I would agree with Wayne that just having this stake in the ground and saying, "You know what?
Outpatient's probably a place a lot of these procedures should be, certainly changes the dialogue.
Brian, I'm just going to add one thing onto that. As you think about the rates here, we believe that we can make money, but this has got to be an and, not an or, right? That's the very simple way I'm thinking about it. This has got to be a positive to volume and bringing procedures in and filling space that we might not otherwise utilize, or where we're making more marginal dollars versus lower contribution procedures, right? That's, I think, part of the reason why we're still also cautious about 2020 and the ramp is that we want to make sure that we're actively managing this to achieve that end result.
That makes a lot of sense. My last question. As I think about Idaho Falls, you mentioned that in your prepared remarks, how should I think about the ramp or the drag from that in 2020 on EBITDA?
The EBITDA drag in 2020 is going to be excluded from adjusted EBITDA as a startup cost. As we've done every quarter this year, we've highlighted what that is going to be for investors. It could be $10 plus million next year, and I think that it will be in that same zip code as the facility opens and we look at what 2019 will be from an EBITDA drag with a lot of that obviously occurring this in the fourth quarter.
The only thing I'd throw in there, having opened a number of new hospitals, I've never seen a hospital in year one go positive. It's going to be a drag for a while. I will tell you that the turnaround here, we expect in this market, given our context and given our strong position in the market already, our strong value position, even with this new hospital, for a new hospital, we expect it to be a relatively quick ramp. Obviously, every hospital has a period of time it goes through that it has to build so.
Brian, we want to see what the trajectory looks like. We want to see how quickly the facility gets licensed and work with the team out there who's done a yeoman's effort in getting it to this stage. There's a lot of variables in play right now. I'm being consciously cautious in what I tell you right now because we want to see what this looks like when it opens and how quickly it looks like it's going to ramp before we give any real projections or baseline for what this could look like next year.
All right. Thanks, guys.
Our next question comes from the line of Frank Morgan with RBC. Please proceed with your question.
Good morning. I'll stick with Idaho Falls for just a second. Would you remind me, I think that facility is going to be leased, but in terms of, is that correct? Then number two, with regard to your leverage calculations and your covenants, does the startup losses on those facilities, I'm assuming those get excluded from covenant calculations. Then the second question, you mentioned the Montana opportunity. I'd just love a little more color there in terms of what you see as the EBITDA opportunity, the capital deployment required in that market, and just any more color and detail on how much you think that could contribute in 2020. Thanks.
Let me start with Idaho, then I can answer Montana or Wayne can. The Idaho, yes, Medical Properties Trust was kind enough to construct the building and the new parking garage for us. When we take possession of that facility, we will have a lease payment that will essentially be accounted for as interest for the vast majority of that payment, but it will show up in the debt schedule as a financing lease. Our current estimate on that is that it'll be about $105 million plus or minus. We obviously need to finalize the calculations once we take possession. Then don't forget, we do have a very attractive facility that we have put in place in Idaho for the equipment to help for that facility. So that'll be just shy of $30 million as well.
We expect that in the fourth quarter that facility will be pretty close to fully drawn as we outfit the new facility. The losses, our current interpretation of the credit agreement is exactly how you put it. The losses are eligible to be excluded. Because we're taking the debt in, it's matching principle, essentially. You're tabbing the debt on your balance sheet, so you're trying to give a sense as to what the contribution from that is. As we finalize those projections, we'll give you a better sense as to what that is when we report the fourth quarter. We've given you at least some benchmarks as to the type of opportunity that we're expecting over the course of the next few years.
It will be deleveraging.
Yep.
Okay. Great.
Relative to Idaho Falls, yes, just a little bit of background there. This is a market where we have a lot of experience already. We were already a majority owner in the hospital system. We were an owner in the ASC, and then there was also the clinic in the market. If you have a little bit of history here, it's a 100-year-plus physician clinic, so it's a very well-established market. There were some opportunities that we thought that we could really deploy, especially where we saw a lot of the growth going in the market. Similar to what we did in Idaho Falls, we saw this as probably a unique opportunity to start building a broader ecosystem. Step one for us was really to get more ownership in the hospital so that we could syndicate to more doctors that we would like to syndicate.
Also, we took over full ownership then of the ASC, which allows us to get then HOPD rates since it is on campus. There's some, what I would call low-hanging synergies that we'll be able to start driving value. Now, you'll start to see some of that value next year in EBITDA growth, but the real meaningful value will be in 2021, when we get the full year run rate of the ramp-up that we'll do, because obviously preparing the facility for HOPD requires different AC equipment. There's just different things we have to do. That being said, the capital improvements that we had to do and the capital deployed to it, we've already done this year. We've already committed, and so I don't think you'll see much more cash flow outlay going into next year. It's just rather executing on our plans and where we're going.
Future cash flow outlay would be if we do something similar to Idaho Falls. I think our first bet is let's go get the low-hanging fruit and the synergies that are available to us. We've got some good rates in that market. We've got some really strong physicians that would like to syndicate, and we think this will be a good ramp-up, a good story starting both next year. Plus, we'll start to get the full value of owning more of the hospital for the pieces that we retain that we don't syndicate.
Okay. Thank you.
Our final question comes from the line of Whit Mayo with UBS. Please proceed with your question.
Hey, thanks. I'll just stick with one question. I wanted to go back to the three strategic initiatives that Wayne discussed, procurement, revenue, cycle, G&A. I think these are areas that have been called out for some time. I'm just wondering specifically maybe what's changed. Are you finding new cost opportunities? Are there opportunities within the opportunities? I just want to make sure that I'm processing these three initiatives appropriately.
Yeah, Whit. Let me first start with all three of the initiatives, and the easiest analogy I can give you is a nine-inning baseball game, and I would say we're in the third inning of opportunity. We are far from what this company's capable of doing. The first year, just as a reminder, last year when this new management team joined, it's important to recognize that despite the 125-plus facilities, there was no centralized procurement function. Just moving to a centralized procurement function, establishing a GPO, getting new contracted rates, all low-hanging fruit, but things you would expect of a company of our size and scale. Rolling that out across the facilities took time, that's what's happened. Now we're moving to just a very simplification of evolution, which is, okay, We hadn't even moved to preferred implants or preferred pricing.
We were just simply getting better pricing due to the lack of leveraging scale. I would just say that on the procurement front, we have nothing short of 20 new initiatives that are constantly in front of us that are the next round of low-hanging fruit we're going after. On the RCM front, as a reminder, we had so many divergent systems that were submitting claims in so many different ways that the ability to actually go out and actually put in true RCM management best practices was completely hindered by the lack of consolidation of platforms. Through the end of last year and then early this year, we now have over 95% of our facilities all on a single claims processing platform, consistently processing through the claims clearing house and warehouse. With that data now, we can actually take actions on it.
Again, I would tell you, very low-hanging fruit that we've been going after. Last year was the investment year. This year was the execution year. Even on the execution, it just starts opening our eyes to more and more opportunities. Finally, on the G&A front, if you can imagine where we were at on the maturity curve on procurement and RCM, it was the same thing. Last year was we had no centralized benefit plan, and we had 24 different health plans for a company that was self-insured. Obviously, we made that transition last year, and those value creation comes through this year. Now we can get more creative in benefit design. There's always this evolution that we're in, but I would say we're still in very early innings.
I'd say two years in, we're in the third inning now, and we've still got another six innings to go of opportunity just in those three arenas.
Okay, that's helpful.
Thanks for the question, really thanks for everybody's time today. I know this has been an interesting journey the last 18 months, almost 20 months now, as we've been laying out where we were going to take the company. I know as a management team, we're very excited about the progress and where we're at. We're even more excited about hosting an IR Day, which we'll publish more information regarding next year, where we plan to give a five-year outlook and really share with you a lot of the exciting things we've been doing in building this platform asset. Before we conclude our call, though, I do want to take a moment to thank our 10,000-plus associates and our 4,000-plus physicians for their contributions. I know I feel privileged to be able to participate in this journey of improving healthcare and making it more affordable for Americans.
As we execute against our goal to become the preferred partner for operating short-stay surgical facilities across the U.S., it is really the daily efforts of each and every Surgery Partners employee and physician that gets us there. Thanks for joining our call this morning, and have a great day.
Ladies and gentlemen, this does conclude today's teleconference. You may disconnect your lines at this time. Thank you for your participation, and have a wonderful day.