Hello, and welcome to Tenet Healthcare Corporation's third quarter 2020 earnings conference call. I will now turn the call over to Regina Nethery, Vice President of Investor Relations for Tenet.
Thank you. We're pleased to have you join us for a discussion of Tenet's third quarter 2020 results, including an update on the impact of the COVID-19 pandemic. Tenet's senior management participating in today's call will be Ron Rittenmeyer, Executive Chairman and Chief Executive Officer, Saum Sutaria, President and Chief Operating Officer, and Dan Cancelmi, Executive Vice President and Chief Financial Officer. Our webcast this morning includes an accompanying slide presentation, which has been posted to the investor relations section of our website, tenethealth.com. Listeners to this call are advised that certain statements made during our discussion today are forward-looking and represent Tenet management's expectations based on currently available information. Actual results and plans could differ materially. Tenet is under no obligation to update any forward-looking statements based on subsequent information.
Investors should take note of the cautionary statement slide included in today's presentation, as well as the risk factors discussed in our most recent Form 10-K, subsequent Form 10-Q filings, and other filings with the Securities and Exchange Commission. With that, I'll turn the call over to Ron.
Thank you, Regina. Thank everybody for joining us today. Our third quarter results, I believe, underscored the operational discipline that we've put into action on an ongoing basis. As the pandemic has continued to evolve in waves, we have successfully met each sharp turn with a carefully coordinated and active response. Every step we have taken remains anchored by our commitment to the highest standards of quality and safety. We're very pleased with the performance of each of our business segments during the quarter. Despite the COVID-19 case surge, which was about +60% in late July and August compared to the second quarter across our system, we delivered a solid performance in every part of our business. While we experienced the surge, we safely handled caring for COVID and non-COVID patients.
Notably, our performance overall for the quarter was strong in delivering EBITDA at $621 million without grant income. Additionally, our free cash flow was 26% above 2019 before grant and Medicare advance dollars were considered, due in part to significant improvements from our Conifer operation. Due to the new guidance issued by HHS in September, which was markedly different than the original guidance we had in June, we had to reverse $70 million from Q2 in grant dollars, thus lowering our reported Q3 EBITDA to $551 million.
We strongly believe this guidance from HHS does not recognize the structural differences across complex networks involving multiple hospitals, including mixed differences in reimbursement levels in the different service areas, capital investment made in 2019 and early 2020 to effectively improve patient access and quality, as well as the incredible losses experienced in the shutdown that need to be recovered to ensure sustainable operations. We continue to discuss these details with HHS in hopes of a more balanced outcome. Regardless, remain optimistic on our performance and our ability to continue to improve. What should be more evident is that the operational enhancements we've highlighted on the past earnings calls have played a major role in continuing to provide benefits across the enterprise. Our continued performance should substantiate these are not one-time events, but sustainable and critical foundational improvements.
For example, enhanced analytical tools and pull-through of precise real-time data, which we continue to refine and develop with deeper insights. Knowledge sharing from COVID learnings real-time across the company, summarized and transmitted in technical and operational scheduled calls that have resulted in improved response to patient needs and an average staff infection rate of approximately 3.75% versus a national average of approximately 13.4%. That focus ensures we remain open to both COVID and non-COVID cases safely and effectively, even while dealing with isolated market surges such as in the third quarter. We've also demonstrated solid, sustainable controls, which include responsive workforce adjustments and tightly controlled labor market management. Continued development of our IT platform, focused on delivering a streamlined set of tools, utilization of cloud-based infrastructure, and a much-improved cyber platform, better purchasing and contracting methodologies, tighter capital controls, and allocations based on defined needs by market.
We've also added highly qualified physician groups based on community need, tighter controls in the Tenet Physician Resources group, and consistent improvements to ensure physicians have an efficient and effective methodology to assist in their ability to support patients. Finally, the continued expansion of our very capable and effective Global Business Center in Manila has been an important enhancement to our 24/7 support model. In the hospitals, volumes for the quarter ended close to 90% of pre-COVID levels. This is continuing to be a solid recovery during the time period and remains very positive. Our operators across our markets have responded very well, given the nature of the complexities of the pandemic, and we continue to perform tightly aligned to the volumes presented.
We've experienced historically high growth in net patient revenue per adjusted admission, driven in part by a higher mix of more complex procedures and a stronger commercial mix, coupled with the sustained efficiencies we've gained operationally. Importantly, this set of improvements is represented both in the hospitals and at USPI, further emphasizing the critical nature of how hospitals and USPI play an integral role with each other, including sharing best practices. We realize and operate every day with the assumption that COVID spikes will be part of what we face until a vaccine becomes widely deployed. We've learned how to deal with these spikes and have done so effectively. We also are aware the pandemic remains a threat, and our focus on staff and facility safety will continue to be paramount in our daily approach.
We continue to use resources internally and externally, including contract labor, to support our operations as needed. We remain engaged in securing sufficient PPE, supplies, and medications to ensure we have adequate coverage. Most importantly, we also realize that agility, speed to respond, and the need for clear, precise communications, coupled with a strong and responsive real-time analytical platform throughout our system, is a critical part of remaining in control of these changes and surges. There is no perfect equation, but we do believe our learnings from each spike improves our responsiveness, our planning, and furthers our effectiveness.
At USPI, the quarter was very strong, demonstrated first and foremost by solid performance, but also carried by excellent quality and service recognition, service line expansion, and the growth of our medical staff. Excluding grant income, USPI had a significant EBITDA growth of 10% over prior year.
As you can see on the volume charts, surgical cases remained relatively steady in terms of volume month-to-month, ending with September growth at 96% of the same period last year. Even with the impact of the various shutdowns and cessation of nearly all elective care that began in the first quarter, the USPI team has remained diligent about energizing various operational programs to enhance facility offerings and expand our network. This includes adding service lines and complex procedures that benefit patients and physicians alike. Despite the pandemic and its disruption, we have successfully expanded our offerings at existing facilities with 54 new service line starts year-to-date, including 24 musculoskeletal programs and outpatient joint growth of 51% year-over-year.
Another remarkable stat that underscores our reputation in the market is that we've added 1,100 new surgeons who have joined our USPI medical team during the first nine months of the year. USPI facilities also continue to earn high marks for patient experience, including Press Ganey Awards last month for delivering incredible patient-centric care. Additionally, 23 of 24 eligible USPI surgical hospitals earned a four or five-star rating in the July 2020 HCAHPS star rating as administered by CMS. Particularly during COVID, we have adhered to the highest quality and safety standards. Out of more than 688,000 USPI surgical cases performed from mid-March through September, we have not had a single confirmed case of COVID as a result of performing a surgical procedure at our facilities.
At the development front, we closed on the acquisition of an ASC in Washington and a new surgical hospital and ASC in the Central Valley of California in July, together with local physicians and two of our existing health system partners. Fresno Surgical Hospital is very well-known in the community, with a rich history and a strong reputation for quality and patient experience. In fact, years ago, the hospital became one of the first facilities in the country to provide elective surgery and post-surgical care in a non-hospital setting. Going forward, our pipeline remains active, with opportunities to strategically add to our network in Q4 and next year.
We're very enthusiastic about continuing our stated strategy to put muscle behind USPI to grow the platform and provide physicians and patients with more convenient options for care, and to continue to evaluate our hospital portfolio for fit, and make adjustments in that portfolio as we deem appropriate. Conifer continues to execute very well despite the pandemic, providing value to its clients with its traditional end-to-end solution and its newer point-of-service solutions. Conifer has remained focused on client satisfaction, performance, and liquidity. I want to call out a few metrics that speak to certain improvements. First, cash collections are up substantially as compared to the third quarter of last year. Second, Conifer AR days or Tenet AR days are significantly down versus the prior period. Third, client satisfaction continues to improve, maintaining a very strong positive trend.
Fourth, expense controls remain solid with an EBITDA margin improvement of 270 basis points versus the prior year. These steps forward are particularly notable given the extreme challenges created by the pandemic for Conifer. The Conifer spin remains ongoing in terms of the pre-work already discussed. Our view is the same as last quarter regarding the spin, and we continue to maintain focus on the previous schedule. We have filed the appropriate paperwork on schedule with the IRS, so that important step is now underway. Beyond that, we continue to search for a new Conifer CEO and have made several meetings with several viable candidates in this process. The team overall, though, is performing very well, and we are pleased with the overall performance of the business.
Before turning the call to Dan to provide an overview of our financials, I'll speak briefly to the critical support we've received from the federal government related to the pandemic. The Medicare advance payments have been a critical source of liquidity, allowing us to focus on caregiving. Recently, the repayment terms for these advances were amended, allowing for an elongated capture period by CMS, as well as a more reasonable interest rate for any balance outstanding at the end of the recapture period. We expect to make the repayments within the allocated recapture timeframe and greatly appreciate this flexibility provided by CMS and HHS. The CARES grant stimulus funds have also been extraordinarily helpful.
As I mentioned, HHS recently issued new guidance for the recognition of revenue associated with the stimulus funding, which has had a major impact on our results this quarter due to the reversal from the second quarter. While the change in methodology will reduce our flexibility, we're taking steps to ensure the change does not negatively impact us over time. Our system, as I've mentioned, has incurred a larger number of COVID cases, in general, and we feel that we've taken it in stride. The change in methodology will place additional pressure on us in the recovery over time, relative to the COVID cases. We also believe we will continue to recover, these CARES grant stimulus funds. It will just be over a longer period of time than we thought we were originally going to, based on the June guidance.
Again, we're not concerned that it'll hurt us over time. We just think it is unfortunate that we had to make the change. As I turn the call over to Dan, I want to note how pleased we are, that we're able to take advantage of the capital markets, position us even more favorably in terms of both debt maturities and interest rates. While we do have many more hurdles yet to overcome, the performance of the teams across the entire Tenet portfolio remains excellent. Our performance in safety, quality, and financially, despite the pandemic, is very positive. While we can sit here and parse various points and speculate on the unknown, factually, we have consistently delivered results at or ahead of expectations before and during the pandemic. I'm very proud of our caregivers and our support staff for their continued excellence.
With those comments, I'll turn it over to Dan for a discussion of the financials. Dan?
Thanks, Ron, and good morning, everyone. I also want to thank our frontline caregivers and employees across the company for their incredible efforts and exceptional execution during these very difficult times. I'll begin my remarks with slide five. As you can see there, we produced a very strong quarter from several perspectives. Our adjusted EBITDA of $621 million, before the $70 million grant income reversal due to the new government guidance, was substantially above our expectations for the quarter, despite the surge in COVID in many of our markets. Also, the EBITDA was above consensus estimates, when you exclude the grant numbers that were in the consensus numbers. We generated very strong net revenue per case growth in our hospital and ambulatory businesses due to a mix of higher acuity cases and a more favorable commercial payer mix.
Our continued tight control of cost mitigated the impact of incremental expenses from the pandemic, including higher temporary labor, premium pay, and PPE costs. We also generated solid free cash flow in the quarter of $331 million or 26% growth, even if you exclude stimulus monies we received. We were pleased to be able to timely access the capital markets and eliminate any significant debt maturities until June 2023, while also reducing future annual cash interest payments by about $60 million. While we typically do not comment on consensus, we realize that the level of stimulus grant income in the consensus is not always readily apparent to everyone. We estimate the third quarter consensus estimates reflect an average EBITDA benefit from grant income of about $70 million.
This compares to the $70 million negative reversal of grants that we had to record this quarter due to the new guidance. Turning to our individual business units, each segment continued to execute well, demonstrating the ability to operationalize the strategic direction of the company despite the day-to-day difficulties of the pandemic. Our hospital segment produced historically high net revenue per adjusted admission growth of about 17%, driven by a combination of higher patient acuity, more favorable commercial trends, as well as negotiated rate increases. This helped confront the incremental labor and supply costs associated with the significant increase in COVID cases over the summer.
Our COVID admissions, during the third quarter, were approximately 60% higher than what we experienced in the second quarter. USPI ambulatory business generated strong top-line growth with revenues per surgical case up 13% on a same-facility system-wide basis, which drove surgical net revenue growth of 6.3% compared to last year. This growth was also attributable to higher patient acuity, as well as growth in procedures from newer service lines. In terms of adjusted EBITDA, USPI delivered a year-over-year growth rate of 10%, excluding a $13 million grant income reversal. Despite surgical volumes being about 6% lower than last year, USPI's adjusted EBITDA margin for the quarter, excluding the grant reversal, was 20.4% compared to 39.7% last year. Conifer also continues to exceed our expectations, especially its cash collection performance for our hospitals and its other clients.
Conifer's adjusted EBITDA was 7% higher than last year, and as Ron pointed out, its margins increased by 270 basis points, primarily due to various cost efficiency initiatives that they've been executing on over the past several quarters. Let's turn to slide six now and review how our volumes trended during the quarter. Despite the surge in COVID cases, hospital admissions, ER volumes, and surgeries held relatively steady compared with the month of June, while outpatient visits grew as patients became more comfortable with the safety of seeking elective care. Clearly, more complex and emergent procedures have recovered from the pandemic at a stronger pace than less critical, lower acuity care.
ER volumes are an example of more critical care recovering at a faster rate, as ER inpatient volumes during the quarter were about 93% of last year's levels, while outpatient ER volumes were about 74% of last year's levels. As I mentioned earlier, the higher acuity, more emergent mix drove our very strong hospital net revenue per adjusted admission growth of 17% in the quarter. Our USPI surgical volume trends improved during the quarter compared to the month of June, recovering to about 96% of last year's levels in September and 94% for the entire quarter. Similar to our hospitals, USPI's more critical, higher acuity cases have rebounded at a stronger rate than lower acuity cases. This mix also drove USPI's very strong net revenue per case growth as well.
Although not on the slide, if you look at the supplemental materials we posted, you'll also see on page six that USPI's nonsurgical visits grew about 8% in the quarter, and that was driven by very strong growth at our urgent care centers. Let's now move to slide seven, which reflects how our EBITDA trended each month during the quarter with and without the stimulus grant funds. As we mentioned last quarter, we are providing this monthly information externally in the interest of full transparency, given the unprecedented nature of the pandemic. As a reminder, the top section of the slide shows our monthly EBITDA in the quarter without the grants. The middle section of the slide highlights the grant income we recognized in July and August before the rules were changed.
Then we also point out the amount we had to reverse in September due to the new guidance. The bottom section of the slide summarizes our EBITDA, including the grant activity. You'll see in the top section of the slide, even as COVID cases began to ramp back up again in July, our EBITDA in July, excluding the grants, was $220 million, which was consistent with the month of June. COVID cases continued to accelerate, our August results did moderate, but our EBITDA in September grew sequentially as we continued to adapt operationally and COVID levels declined.
Important point is that before the grant reversal, our $220 million EBITDA performance in the month of September was above our original pre-COVID budget for the month, even though our volumes were about 5%-25% lower than last year, depending on which volume metric you look at. Overall, we were pleased with how our operators managed through these times and produced EBITDA for the quarter before the grant reversal that was substantially above our expectations despite the elevated COVID-19 levels. Next, let's go to slide eight and review our liquidity. We currently have sufficient cash resources and available liquidity under our $1.9 billion line of credit facilities. As of Monday, we had approximately $3.3 billion of cash on hand and no borrowings outstanding under the line.
Let me now provide an update on Medicare advances. As you may recall, we applied for and received approximately $1.5 billion of accelerated payments, substantially all of which was received in the second quarter. Originally, repayment of the advances was scheduled to begin in August. However, in the continuing resolution signed by the President on October 1st, the repayment timeline for the advances was extended.
The repayment period now begins next April, April 21, rather than this past August, and extends through September of 2022. Also, any balances not repaid by September 22 will be subject to a 4% interest rate rather than a 10.25% rate under the original repayment terms. We certainly appreciate this government support and the repayment period being extended as it alleviates a substantial near-term cash outflow providers were facing while confronting the challenges of the pandemic. Also, just an update on the amount of grant funds we received. We received additional stimulus grant funds of $178 million in the quarter. To date, we've received about $890 million of grant funds. Of this amount, $453 million has been earned so far and recognized as grant income.
Given the new guidance and the uncertainty as to the level of future COVID cases and costs, it is difficult to predict with any precision how much of the remaining grants of about $437 million will be earned by us in future months. Before I wrap up my remarks, let's now turn to slide nine to discuss our noteworthy cash inflows and outflows during the quarter. You may recall last quarter that we discussed our objective was, despite the pandemic, was to not burn through a material amount of cash in the second quarter, excluding stimulus funding and proceeds from issuance of new notes. We did accomplish that last quarter, and we did so as well again this quarter. In fact, in Q3, we produced strong net cash flow growth, excluding those items I mentioned, of about $231 million.
One other item I wanted to point out was that we did accelerate $105 million of interest payments into the third quarter that normally would have been paid in October, and that was due to us early retiring our notes that were scheduled to mature in 2022. We also continue to be very diligent and thoughtful about how we allocate capital, including CapEx. You'll recall at the outset of the pandemic, to ensure we preserve sufficient liquidity, we dialed back our anticipated CapEx spend for 2020 by about 40% to $425 million from our original estimate, which was $725 million. Given the various actions we've taken over the past two quarters to enhance liquidity and our improved cash collection trends, driven in large part by Conifer's strong performance, we now estimate that our 2020 CapEx spend will be about $525 million.
These additional investments are primarily attributable to growth capital opportunities and necessary spend for COVID. With that, I'll end by saying again that we are incredibly grateful for the unwavering efforts of our patient caregivers and the employees during the pandemic. I'll now turn the call back over to Ron.
Thanks, Dan. I have really no other comments to add. I think we've covered everything. I think it'd be smart if we get into questions. We've got about half an hour, I guess dedicated left here to cover questions. Operator.
Thank you. The Tenet management team is now ready to take your questions. To help ensure all those in the queue are given an opportunity, Tenet asks that you please limit yourself to one question. If you'd like to be placed in the question queue, please press star one on your telephone keypad. Once again, that's star one to be placed in the question queue, and we ask that you please limit yourselves to one question. Our first question today is coming from A.J. Rice from Credit Suisse. Your line is now live.
Hi, everybody.
Hi, A.J.
I probably don't have to ask. It sounds like you guys have obviously been trying to do assessments of the market data analytics around these different hotspots, and you sort of had a unique portfolio where you had some markets that were hit early on pretty hard, and then you're in other markets that have had hotspots develop. Can you maybe just drill down a little bit on how you feel you are at being able to predict where the next hotspots are going to be, what you've learned in terms of managing through a hotspot, and also assessing how the community's managing through that hotspot and then coming out the other end and recapturing deferred procedures and things like that?
Okay. A long question there.
Sure.
Saum, do you want to handle that?
Yeah, sure, A.J. Thanks for the question. I think in terms of predicting where the hotspots are going to be, we obviously follow very carefully a lot of the public health information that's available with respect to new testing, positive testing incidence rates, and you can really track the spread of the virus that way pretty quickly. Obviously, by the time these cases are hitting our urgent care centers or emergency departments, it becomes quite obvious there's going to be a surge.
What we've learned is, generally speaking, there is somewhere between a four to six-week cycle that you'll go through in a market when there's a COVID surge. Usually, there's a couple of weeks of ramping up. You end up spending about four weeks at a high-level plateau. That mix includes both med-surg and ICU patients. It sort of ramps its way down.
Our priority during that phase, obviously, is maintaining a very good throughput in operations within our environment, separating COVID from non-COVID care. Our focus on having adequate PPE and testing has allowed us to make sure that we are able to process those patients adequately, but also keep our staff safe. We've not had, especially in recent surges, any need to shut down procedures or elective surgeries. That's a very important point because we want to maintain access for the community.
Then as those cases ramp back down, we ramp back up very quickly. That's probably the most important thing that I focus on, which is at the end of that six-week period, that recovery work is a playbook that we've got down from having had a number of markets go through surges. Our September results are very much a reflection of that.
If you look at the COVID activity in the quarter, it was very much spiking in the first part of the quarter. By the end of the quarter, as those cases had ramped back down, we're very capable of getting back to normal business, getting anything that was deferred on the schedule, and most importantly, working with our community and doctors, to ensure that the patients in the community realize that they can come back into the hospital for necessary care. That really is why when you look at September, the results reflect basically our ability to get back to business as usual from patient care and from an earnings standpoint.
Okay, great. Thanks.
Thank you. Our next question today is coming from Josh Raskin from Nephron Research. Your line is now live.
Hi. Thanks.
Hey, Josh.
Good morning. Appreciate you guys taking the questions. Hi, Ron. I wanted to ask about the increase in revenue per adjusted admission and just try to break out the buckets there. How much of that is coming from actual COVID patients? It sounds like that was a bigger impact than I had expected. How much of it is mix, specifically commercial, and how much of it is actual acuity? Within that, how are you and your physician partners prioritizing the patients and the procedures that come back first? It sounds like you're getting more of the high acuity and more of the commercial back, and I assume that's similar in ASC.
Dan?
Hey, Josh. It's Dan. I'll start off and then Saum going to address the last point. Listen, the 17% growth in the revenue per case on the hospital side, all three of those components have some element to it. The predominant factor driving the growth in the net revenue per adjusted admit is due to the higher acuity cases. Listen, COVID's part of that, right? That's not the primary driver of it. You have the mix of higher acuity cases. You have a stronger commercial mix, compared to our overall volume trends, which makes sense to a large degree.
Medicare patients are probably a little more reluctant to seek care unless it's necessary. The commercial trends are more favorable than the overall trends. There's also the growth in the revenue yield due to our contracting position. We've been very clear about that over time.
We're very well contracted this year and into next year. Our growth, just from negotiated rates, depending on the facility, and depending on the payer, can be 3%, 4%, 5% or so. They've all played a part. Let me just address this COVID, and the revenue yield from that. I would say this before I turn it over to Saum. Yes, in aggregate, the net revenue for COVID cases is higher than the overall net revenue per admit. Okay? You got to keep in mind, you have to case-mix adjust that rate. There is obviously incremental cost caring for those type of patients. When you case-mix adjust that rate, it's very similar to what our overall net per admission is.
The other thing I'd point out in terms of the mix of the COVID patients, COVID patients related to commercial payers is roughly 20% of the total COVID cases. The other 80% is either Medicare, Medicaid, or uninsured. As you well know, obviously, the commercial reimbursement would be more favorable than the other payers. Again, it's very important to consider the fact that when you case-mix adjust those particular type of services, and consider the incremental cost associated with them, the profitability isn't necessarily there that a lot of people think is there. I don't know if there's anything else you wanted to add, Saum.
Yeah. I'd make a couple of points to you again, just thinking about what I said, which is the most important thing to really look at is the nature of the recovery. Let me frame it this way. When you think about the number of COVID cases from the beginning of the quarter declining at the end of the quarter, and we're basically able to maintain and rebuild the business at roughly 10%. Under prior year. The thing I would tell you is that as Dan pointed out, the commercial admissions performed better than that. More importantly, given our long-term strategy of building a base of higher acuity procedures and services, our commercial surgeries, and you can see the surgery numbers look more attractive, even the commercial surgeries were performing, by the end of the quarter, better than those averages.
Surgeries are not really relevant in the COVID environment. What we did was we built back consistent with our long-term strategy, the strength in the surgical environment that we have been pursuing for the last couple of years, including having a number of markets that were performing better than prior year, especially in commercial surgeries. If you say, what's driving that? Well, even over the last four or five months, and primarily in the last quarter, we've opened up and built two new trauma programs. We have a new and expanded neurosurgical and spine program in South Florida across multiple hospitals that's been coordinated. Big push in surgical oncology and building a network in San Antonio.
There are just a number of things in rebuilding the strength in our business, very specifically consistent with our long-term strategy, that we have continued to execute on over this period of time. That's helping to drive the strength in the recovery. As I pointed out before, the COVID cases may come and go. Even on a commercial basis, because the costs of those cases are high, I would never want to substitute a COVID commercial case for the types of business that we're building. We obviously do the best we can to take care of those patients, but we're very quick to recover in the normal lines of business that we've been strategically focused on.
Perfect. Thanks.
Thank you. Our next question today is coming from Justin Lake from Wolfe Research. Your line is now live.
Hi, good morning. This is Eugene on for Justin. Thank you for the question. As a follow-up to Josh's question earlier, are you able to quantify the number of COVID-related admissions during the quarter? I think you said COVID mainly impacted July and August, so can you comment on how your admission volume and acuity were tracking towards the end of September and possibly early October? Thank you.
Yep, this is Dan. Let me address a couple of those points. The COVID inpatient census in the third quarter was about 15,000 cases. As we pointed out in our remarks, it's roughly 60% higher than the second quarter. One thing that's important to keep in mind with the previous conversation we were just having, the sequential change in earnings from August to September was not due to the mere growth in overall cases. In fact, our admissions were actually about 1% lower in September compared to August. You see the impact of the COVID cases have on earnings. In August, when the COVID cases were higher than September, it did. It had an impact on earnings. That sequential growth in EBITDA from August to September was not just due to, well, cases were higher normally because th at's sequentially what happened.
Our aggregate volumes in September were roughly down 1% compared to August. You see the growth in the earnings from August to September as the COVID cases declined.
Thank you. Our next question today is coming from Pito Chickering from Deutsche Bank. Your line is now live.
Good morning, guys. Thanks for taking my questions. I'll sort of ask the same question in a different way. There's obviously a pretty big debate on the investor community about the sustainability of hospital EBITDA observed during third quarter. A multi-part question, any chance you can give us how much EBITDA in third quarter came from COVID, and more specifically, how much you saw in September? I understand this doesn't give a whole picture, but at least help us understand how that works. More importantly, can you give us color on your October trends, what you've seen, what are you seeing in November OR scheduling blocks of times? Then walk us through sort of the headwinds and tailwinds to help us think about the revenues and margins over the next few months.
Well, that's three questions. We'll do our best. Dan, you want to start?
Hey, Pito. It's Dan. Let me try to address that and Ron or Saum can fill in. We obviously haven't provided EBITDA by service line. Again, I'll go back to when COVID levels were much higher in August, it had an impact on our earnings in August. You can see the sequential change from August to September. Again, our aggregate volumes from August to September were roughly flat or down about 1%, so let's just call it flat. Earnings increased, and in large part, that was due to COVID cases leveling off and coming down. The COVID cases have substantially more costs associated with them, particularly if a patient ends up in the ICU.
I said earlier, yes, the revenue per COVID case that we've experienced per admit so far is higher than our aggregate net revenue per admit. Again, the CMI or the acuity, Pito, as you know, of those cases is higher, and that brings with it incremental cost. That's why I said, when you case mix adjust it's pretty close to what our average net per admission is. Saum, I don't know if there's anything else you wanted to add.
Yeah, I think a couple of things. I think it's important to realize that the nature and mix of our COVID activity, given the markets we're in and the especially types of urban centers that we have, as Dan pointed out earlier, they're not mix enriched. In fact, relative to our average, it's slightly below our commercial mix. We're dealing with a lot of work in the Medicare, Medicaid, and even uninsured space with respect to the COVID care that at least we're seeing in our system. Again, a consequence of some of the markets that we're in. When you look at September, again, I don't have any other way to do this but to just continue to give additional examples of what we're doing to drive the recovery.
In addition to some of the stuff I mentioned before, we've had expansions in many of our surgical service lines, very consistent with our strategy over the last couple of years. We've built the robotics and urogyn program in El Paso. We've got rehab facilities that we've expanded in South Carolina. We've got a CT surgery program that has gone through material expansion in parts of Texas. Our point has been continuing to advance this strategy of expanding surgical service lines for the community as a way to drive and be prepared to manage the recovery over time, recognizing that some of the lower acuity business that was in hospitals, let's say very low acuity ER visits, may take a long time to come back. We're not trying to create a replica of what 2019 looked like from a mix.
We're looking at where the market is headed. We're trying to address that market as part of our recovery. Not surprisingly, the comments that Ron made earlier about USPI, we're tracking exactly the same way. The expansion of our physician staff there has been in primarily higher acuity specialties. The number of orthopedics programs and even the number of orthopedics cases, for example, in that environment, has grown materially because we're basically servicing where the demand is rather than trying to create a replica of 2019. I think that's going to end up serving us well over time rather than trying to wish for everything that was in the hospitals, including the low acuity business, to come back. It ought to drive an enhanced earnings profile because of the case mix intensity and net revenue per case that becomes more sustainable.
Any color on the October and November trends or scheduling? Thanks.
We don't show any signs of a shift from the strength that we saw in our September recovery as I look forward. I can look at that at any metric, whether it be our scheduling of cases at USPI or the hospitals from a surgical standpoint or high acuity service standpoint that we're looking at this point in time at all.
Thank you. Our next question today is coming from Whit Mayo from UBS. Your line is now live.
Hey, thanks. Good morning. I wanted to shift topics a little bit and go back to USPI, maybe for Saum or Brett, the 1,100 new doc adds. I was wondering if you could frame that relative to your current base, and I think I heard Saum say that in terms of specialties, I think ortho was certainly an additional benefit there. Are you re-syndicating more equity to these doctors or these doctors that are just moving their business? I guess I'm trying to frame how sustainable you think the volume is from the new 1,100 doc adds?
Yeah, Brett, please comment.
Yeah. Hey, how's it going, Whit? Just to back up a little bit, we've certainly seen an increase in the number of physicians that are interested in operating in the ASC setting, that's without question. As Ron mentioned, we've added over 1,100 physicians to our medical staffs just this year, and that's partly as a result of COVID, but I think the increase is more related to our ongoing business development and service line expansion activities. There's no question some physicians are moving more of their business to ASCs as a result of patient preference related to COVID, but others are simply continuing to find it's a more efficient site of care for their surgical patients.
If you, going back to your question related to how much of an improvement that is over our base, you think we have about 4,000 physician partners across the portfolio, about 10,000 physicians on our medical staff. This represents, in a nine-month period, over a 10% improvement. And the number of physicians on our medical staffs overall. I don't have a specific breakdown in terms of how many of those are partners versus non-partners. As you know, most physicians join our medical staffs, they make sure it's a good fit for them, good fit for their patients, good fit for the overall partnership, and then at some point down the road, they may exercise the opportunity to actually buy into a partnership. That's not our focus day one.
Our focus is making sure that we bring in the right high-quality physicians to our medical staffs, that they're happy with the service that we're delivering to them and their patients. Over time, we add those physicians potentially as partners to our facilities. I think the number and the amount of physicians that we've added to our medical staffs over the first nine months is clearly better than we have in historical years. Again, primarily, I think, a result of our business development activities and our service line expansion activities. To a minimal degree, a result of the COVID-related activity.
Perfect. Thanks a lot.
Thank you. Our next question today is coming from Brian Tanquilut from Jefferies. Your line is now live.
Hey, good morning. I guess I'll follow up on that comment from Brett and Saum's comment earlier to Pito's question. Do you guys think that there's a structural change that's happening that's actually not a bad thing, where you're pushing more procedures or visits either to the ASC, whether it's joint replacements or ER visits that are low acuity going to urgent care? How do you think that, if that's the case, what should be the margin outlook going forward?
Yeah, that's a good question. Let me clarify what I said before, which is, what we're focused on is understanding where the demand is today and making sure that we're leading the charge in helping to service that demand by shifting our focus into the areas where we see that activity happening, in other words, the higher acuity surgical, higher acuity emergency department. We track very carefully even our emergency department visits by acuity level. At the higher acuity levels, we're performing better than we were in prior years. Those data have some lag to them. When we look at our own data, we're convinced that in our high acuity ER business, we may be moving market share. Again, we're very focused on that.
The clarification I would offer is, look, I'm not yet committed to saying that there is a major shift in the demand pattern that's permanent as a result of COVID, especially in the lower acuity areas. When I look at the areas, lower acuity areas in particular, that are down quite a bit. For example, they're much more down in pediatric visits than in other services, especially in the emergency department, okay? Schools are not back online. Sporting programs that kids are in are not back online. I don't know that that's some sort of a shift from the ER to the urgent care setting.
I just think demand is down because activity is down because of partial stay-at-home orders that are still active in many of the markets we're in. I would say that's true for a variety of other activities that result in ER visits. You're not going to get a broken bone fixed and set necessarily at urgent care centers permanently in the future or in other centers. I actually think some of that demand will come back as the communities fully open back up, schools fully open back up.
Other things, but it may take some time. My point was attempting to work that side of the equation right now doesn't make a lot of sense. Again, I'm not yet committed to the concept that demand is gone forever from hospitals. We'll see how that plays out over the next year or two. It's clear that telemedicine won't be able to service a lot of those types of injuries and stuff that drive a lot of low acuity ER visits. It'll go somewhere. It's just a question of how much will come back to hospitals. Does that help?
Yeah, no, that's exactly what I was looking for. Thank you. Appreciate that.
Thank you. Our next question today is coming from Kevin Fischbeck from Bank of America. Your line is now live.
Great. Thanks. I want to get a sense of how you're thinking about the incremental profitability of volumes returning back to normal. I guess, obviously, usually we think about incremental volumes coming with a nice fixed cost leverage. If we're talking about lower acuity volumes coming in, how should we think about that? I guess incrementally, you've been able to manage labor. Does that get more difficult as volumes come back? I'm just trying to think about the interplay of low acuity and potentially labor cost pressure as volumes come back, and how we should think about incremental margin on future normalized growth. Thanks.
Yeah. That's a good question.
Saum, do you want to-
Yeah, I can start, and Dan, you can maybe add on. It's a good question because, as you move to a higher acuity mix, obviously you're going to need more support and staff, especially in the ICU and critical care units and other things. Thus far, we have not seen a tremendous amount of pressure related to the work that we're doing more strategically in expanding in those areas. I would point out again that as COVID surges come through, we have had to use a fairly significant amount of contract labor in the quarter, especially in the first couple of months in the quarter, that affected our costs. We've been very disciplined about
Using the question that was asked earlier, I think by A.J., about the predictability of these COVID surges and declines, we've basically gotten pretty good at just estimating how much contract labor we're going to need for how many weeks, and then shutting it off, sometimes in advance of the surge disappearing, because we know what the curve is going to look like. That really is reflected in our September results, from the standpoint of managing margins. Look, the other thing I would say is, there's no question about the fact that the foundation we've laid over the last couple of years to have a more daily-driven management process in our, not just labor productivity, but labor mix, that we are utilizing for patient care has served us well, and probably has accelerated some of our recovery.
We have no intention of changing from that approach to management, even if the COVID activity dissipates or goes away more permanently with the vaccine. We know it's our responsibility to continue to drive efficiency in that setting. Probably the more important opportunity looking forward for us is also in the area of purchased services, in many cases, which are labor-based, right? Many of the services that we have either partnered with outsourcers or others, where we're really working on managing the productivity of that staff at the same time. That'll result in incremental opportunities for savings, as we right-size effectively to the portfolio of cases that we're seeing in the hospitals these days.
I'd just add to that whole concept that Saum just talked about also spills through, that we talked a lot about all the way back through our overhead and our overhead operations. Our global business center will continue to play a major role in better allocation of overhead and better allocation of support, since that's a 24/7 type operation, and it's staffed accordingly, and it can be very responsive. It's done a great job through the pandemic. We've actually more than doubled the size of it through the pandemic, even while it was going on. That has proven to us to be a great source of balancing workload and balancing it in the right places, with really good talent. At the same time, being able to be much more responsive to our facilities on a 24/7 basis.
Dan, do you have anything else you want to add?
The only other thing I'd add, Kevin, is you'll recall before the pandemic occurred, that we had been focused on, over the past several years, realizing about $450 million of cost efficiencies since we started this back in 2018. We're fully on track for that for this year. As we talked about last quarter too, as a result of the pandemic, we've dug deeper. We've identified more efficiencies that we've been realizing or will realize into the future. It's really across all the cost elements of our cost structure, whether it's labor management, supplies, or other operating expenses. Saum's point about some providers that were in other operating expenses. We've been renegotiating contracts, improving SLAs or service level requirements, and it's had an impact.
We also, at times, will take actions to terminate a contract, even if it costs a little bit of money to get out of it, if long-term, the return is going to be better. Obviously, we'll keep working on this, and we feel very good about our ability to continue to manage costs well.
Yeah. The last point I'd add too, Kevin, is that we've added a significant amount of analytics, and we look now in a much more database-driven, finite level at where we have people, what are they doing, what's the impact of that? Is there a better way to do it? Where do we automate? Where don't we automate? We approach all of this, I think, with a much clearer vision. The pandemic, to Dan's point, has enhanced and pushed us to question just about everything. I think we've become much more effective at this, and over the next year, we'll even continue going deeper. I hope that answers your question.
Yeah. Perfect. Thanks.
Thank you. Our next question is coming from Ralph Giacobbe from Citi. Your line is now live.
Great. Thanks. Good morning. Just wanted to ask about the EBITDA trajectory. You've been running at a monthly level of about $220 million for, I think, three out of the last four months. The dip in August, I think you mentioned, was related to some of the COVID activity and maybe even some seasonality. I guess the question is, typically we see a seasonal ramp into the fourth quarter. Do you still expect that to be the case and higher EBITDA run rate, or is that maybe unlikely to move from that $220 million, just given the underlying circumstance? Thanks.
It's a great question. Dan, do you want to jump first?
Yeah. Hey Ralph. Certainly throughout the last four quarters have been in that $220 million territory, as you mentioned, as we talked about, August numbers were more moderate because of COVID. We obviously haven't provided guidance, but we're certainly working toward that and then some. The fourth quarter, as you know, is typically sequentially stronger, particularly on the ambulatory side, as well as the hospital side, as patients have met their deductible in a given particular calendar year. Sometimes, we have seen a little bit over the past couple of years that people have maybe managed that a little bit differently than in the past.
Last year in the fourth quarter was incredibly strong. We'll have to see. We don't know, right? We'll have to see how it plays out this year. We are obviously working toward driving incremental volumes in the fourth quarter. You've seen the trajectory with the ambulatory business. It's improved nicely. Again, just putting COVID aside for a second, because if there are significant spikes that obviously will have some type of impact. We're going to be working for sequential growth. I think the big variable is ultimately going to be two things. One, the level of COVID, and two, the comfort and level of patients returning to facilities, whether they're hospitals or surgery centers, for elective care.
Okay. Fair enough. Thank you.
Thank you. Next question today is coming from Gary Taylor from JP Morgan. Your line is now live.
Hey, good morning. Thanks for taking the question. Just a quick one. As we're trying to look through all the COVID impact on all the operating metrics, et cetera, just trying to get a sense of the underlying recovery in the commercial business that you've talked about. It's difficult to look at the revenue mix because that includes your MA business. It also includes COVID. Is there any additional detail you could provide just on commercial adjusted admissions excluding COVID, commercial case mix index excluding COVID? Is there any additional detail or color you could provide on that?
Hey, Gary, it's Dan. As I pointed out earlier, our COVID cases related to commercial payers or exchange payers is roughly 20% of the total COVID cases, which, as Saum pointed out, is slightly lower than our normal pure commercial mix. The other 80% is either uninsured, Medicaid or Medicare. That's the mix of the volumes from a COVID perspective.
I'm sorry. I was saying, if you exclude COVID, and we looked at underlying commercial adjusted admissions growth excluding COVID, is that up, down or flat year-over-year? I'm just trying to parse out the impact of the COVID admissions.
Yeah. Again, as I said earlier, the commercial trends are more favorable than the overall trends for the hospitals. You see the monthly percent of recoveries for the overall admissions, the overall visits, surgeries. The commercial trends are more favorable than the overall trends.
Well, that's helpful, but if we exclude COVID, admissions are down 20%, so commercial is down less than 20%. I guess that's basically what we're going to get to. Okay.
Again, obviously, the hospital volume trends in aggregate have not recovered to pre-COVID levels, and that's the same thing with commercial. The commercial rebound has been stronger than the overall rebound.
Okay.
The only additional point I would add there is that the point I made before, which is, I look more at surgeries, and because that's not really a COVID-related activity, and the strength in surgeries, and in particular in commercial surgeries, is probably the best area to really look at with respect to the recovery. As I pointed out earlier, our strength in surgeries and in particular, to Dan's point, commercial recovering better in commercial surgeries is the strongest marker I have when I look at a comparison across different lines of business there, and I feel very good about that.
Hey, and Saum, to that point, I know Gary wasn't specifically asking about USPI, but we obviously had very favorable payer mix with our commercial mix outpacing governmental. More specifically, Q3 commercial was up 34 basis points, while Q3 governmental was down about 30 basis points. Overall, a positive trend in that regard.
That was revenue mix, right?
Correct.
Okay. Thank you.
Okay. Do you want to do one more?
Sure.
Let's do one more, and then we'll wrap it. Operator, one more.
Certainly. Our final question today is coming from Frank Morgan from RBC Capital Markets. Your line is now live.
Hi, Frank.
Good morning. This one's real quick. Dan, you called out your acceleration in your CapEx program, how you've upped those numbers, and I think one of the things you called out was COVID-related CapEx, and I'm just curious what that would be. Thanks.
Hey, this is Dan. Yeah. The incremental investments that we're going to make is roughly $100 million. It's predominantly related to growth capital opportunities, let me be clear. There is some additional spend that we believe is necessary to appropriately care for COVID patients. I don't know, Saum, if there's anything else you want to add to that?
Yeah. Examples of that would be, there are just equipment and supplies and things, some of which are more capital related. Think about some of the purchases of ventilators and other things that might be relevant in that space. The other infrastructure, there's a little bit of infrastructure spend in there just because, as we pointed out earlier, we've been so disciplined about making sure that we minimize our infections of our own staff because that is, again, that is probably the most important marker in my mind of being able to maintain support in the hospital for always continuing elective work. We've put infrastructure into some of our hospitals, separation of COVID from non-COVID care areas and things of that nature so that it's more structural.
Again, it's all in the spirit of keeping that environment safe and also creating an important perception for everybody who's in and out of the hospital that they're not going to be exposed.
It has the added value of working, which is good. Okay. I think that's it. We appreciate everybody joining. I am sure there will be some follow-ups. We think, again, we feel we had a very good quarter, and we appreciate the time you gave us to ask your questions. Hopefully, we are clarifying and straight as could be. With that, I guess operator, we will conclude the session.
Thank you. That does conclude today's teleconference and webinar. You may disconnect your line at this time, and have a wonderful day. We thank you for your participation today.