All right. Good morning, everyone. We're here on day two of the Global Healthcare Conference for Goldman Sachs. I'm Jamie Perse. Our next session's with Tenet. I'm gonna turn it over to Will briefly, and then to Tom for opening remarks, and then we'll get going.
Cool. Thanks a lot, Jamie. Thanks for ehaving us today. Just a quick comment, we're gonna make some forward-looking statements today. I would suggest that you refer back to our cautionary statement, which was included in our most recent earnings release, as well as related SEC filings, for anything related to that. With that, I'll turn it over to Tom.
All right. Thank you, Jamie, first of all, for having us, and thank you for being here. I'll just make a few brief comments, and then we'll get into the Q&A. A few things about the business. I think probably the most important thing, from my point of view is that, you know, we're at a stage in the recovery where we feel like a lot of the fundamentals that we would exercise in our operations and our operating model, are working on a more predictable basis. You know, it feels good to be in a place where we're not just talking about recovery, but we're talking about the next two or three quarters, but also the next two or three years, and how we think about building back from the pandemic. The fundamentals of growth are strong.
You know, now that we've had enough distance from looking at the numbers for the first quarter, we feel very good about the fact that we've added physicians on a net basis in the first quarter at USPI. That's good. That's the health of our physician practice partners, growing their practices and choosing to participate in our USPI centers. We feel good about the service line mix and the acuity that we're seeing at USPI. I think I talked a little bit about this in the past, but, you know, joint growth in double digits, healthy recovery of the GI business, which is so important to the portfolio, and good diversification and success in our acquisitions, in particular, the urology platform that we now participate in, and some of our other initiatives, in particular in bariatrics and robotics.
We see a very nice runway of fundamentals at USPI to move forward from. In addition, the work that we're doing in that business unit to improve our efficiency, improve operating room utilization, improve our permanent staffing is very good. As you guys know, contract labor is really de minimis in that business unit. We feel very good about where that business unit is going over time. In the hospital business, a lot of very good things happening as well. Volume strength in the first quarter and into April that I had mentioned before. We feel like many of the fundamentals there are improving. ER volumes are up. Our physician practices are busier than we've seen in the past. Our net physician adds are significant in our employed specialty networks. We see elective business improving. We see commercial volume strength.
I think many of the things that are fundamental to, again, the recovery of that business, on the hospital and physician side that we have there, feel good in terms of the investments we make. We have much better predictability than during the pandemic about the returns that we'll generate. Again, as I said, we're starting to think longer term. Not to leave out Conifer, but, you know, Conifer grew, third-party revenue, very nicely. The margins continue to hold, very nicely, and we see a big opportunity there with Medicaid redeterminations. Conifer has a very unique Eligibility and Enrollment platform that serves our third-party clients, that's both on the exchange side and on the Medicaid side, and that package, as a point solution, is beginning to enter the marketplace.
It's timely, and it's a capability that we think health systems will need, even if they don't choose to look at end-to-end revenue cycle outsourcing. We think this will be a nice product to add in the marketplace with the types of results we already get for our third-party clients. Again, I think, you know, a good environment to be in, and a good time to be looking to the future, in healthcare services demand.
All right. Well, thanks for that. We'll come back to a lot of what you touched on. I wanna start just with the utilization environment. You've had a little bit more time to look at the first quarter and, you know, get a sense of what really happened, what drove the growth. What can you say about the sustainability of what you saw in the first quarter? We heard yesterday from a peer of yours, that there may have been some catch-up of procedures deferred in the fourth quarter into the first quarter, and what's your reaction to that?
Yeah, as I, you know, as I indicated in my opening comments, I mean, the growth in the first quarter was multifactorial, you know, there's obviously going to be some rebound effect as we come out of the pandemic. You know, we anticipated that happening last year, if you recall, right? Our assumptions for last year indicated, you know, in some ways that we thought that COVID would be removed from the environment. We haven't seen any material COVID spikes, and we've also seen an environment with improving labor liquidity, and that's a good thing.
When we look at the services that are growing, and we look at the outpatient leading indicators, in particular, the physician practices, which appear to be growing faster than they were a year ago, we know that predictably downstream, we will continue to see the benefit of that outpatient activity with the creation of inpatient demand, more on an elective basis. That's a good thing. We feel like actually many of the fundamentals from a sustainability standpoint, in particular with our initiatives in high acuity care, are paying off, and we're optimistic about that future going forward. At USPI, you know, I think one of the more important things to realize is this is all elective business, largely, right? When we see volume strength there, these are choices that people are making to come in to get a variety of procedures.
As we talked about in the first quarter, probably some of the GI work is a bit of rebound in deferred care, but the strength in all of the other service lines are very unlikely to be, right? Those are near-term conditions that are harder to defer. For us, what we focus on is the efficiency of making operating room available and the growth of our physicians that participate in the USPI centers, which generally indicates that we'll continue to grow over time. We're seeing both of those things improve at USPI.
Do you think we're back to a normal 1Q from a seasonality perspective, and from here, we should see just normal seasonal trends? It's a follow-up to the same question, just trying to get a sense of if there's anything unique about the first quarter that we should, you know, assume doesn't repeat going forward.
Yeah, Jamie Perse, one of the things that's really encouraging on particularly on the acute care side, is we've seen 10 consecutive months of positive adjusted admissions growth since last August. It's not like, there was, like, a big spike in one or two months, which would suggest, you know, there was this pent-up demand, then it tapered off. That's not the case. We're optimistic about that we continue to see month-to-month positive adjusted admission growth in the hospital business.
Okay. You mentioned strength in April previously. Are you able to say anything about.
We're not going to get into monthly-
Okay
... numbers. I would just tell you that we feel very good about where we are today.
Okay. Okay. One thing you brought up on your first quarter call was just some markets are behind other markets, in the way they've handled COVID. You have some markets that are, you know, certainly, you know, Texas and Florida, probably opened up much more quickly. Where's the rest of the portfolio, and is there incremental opportunity in some of the markets that have lagged to kind of catch up?
Sure. I mean, we have a pretty diverse portfolio from a market standpoint. It's probably a bit of a unique feature of ours in the, in the hospital business. You know, for example, in this state, it was just on the end of April, I believe, that the COVID restrictions were removed from the hospitals and the physician practices to try to get them busier. There's, you know, a lot of work going in retooling those operations without those precautions to start to ramp that up. I think, you know, even in this state, there's still some counties that have restrictions different from what the state did. There are, you know, markets that are just slower to open back up than, yeah, to your point, Texas and Florida.
I think that, you know, to the extent that those markets recovered earlier, we should see some tailwind, in these markets that open up a little bit later, similar to what we saw in those that are earlier.
Let's stick with top line, but a couple other components here for a minute. You know, mix has been a really strong benefit. Part of this is just where the market has gone. Some of this has been Tenet-specific focus on acuity. Where are we from a mix perspective and acuity perspective? You know, is there pressure as incremental volumes come back, that we get to a lower baseline for acuity, or are we at sustainable levels?
We've had, from a CMI, Case Mix Index perspective, a measure of acuity, we've had a 3% CAGR growth, since 2019, which is pretty strong historically in the industry to have that type of CMI growth. So it's obviously, the focus on the higher complexity, higher acuity service lines, is clearly paying dividends from our perspective. You know, the mix has been strengthening. Commercial came back quicker, obviously, after the, you know, the pandemic, for obvious reasons. Medicare volumes are strengthening, as you know, you know, the past year or so. That's encouraging.
You know, the lower acuity business, we've made some conscious decisions to limit capacity in certain cases based on, you know, the cost of temporary contract labor. As the contract labor rates have moderated, we've opened up some more capacity, which helps from a volume perspective. Listen, that lower acuity volume coming back will have a mathematical impact on, you know, net revenue per adjusted admission, as an example. We feel really good about our revenue yield on our core service lines and where we are from a health plan contracting position. You know, we would expect to continue to see acuity growth.
Okay. Let's bring in the payer mix element here. You mentioned Medicare coming back. Is that now growing, you know, consistently faster than commercial as there's catch-up? And then also just on the redetermination side, what are you seeing, you know, in these early days of redeterminations in terms of impact on, you know, coverage in your markets and what's coming into your hospitals?
Well, I would say, yeah, Medicare volumes have been strengthening, whether it's fee-for-service or MA. You know, commercial volumes, as Tom mentioned a few minutes ago, have been solid. Again, you know, we welcome additional Medicare volume. We have a very efficient platform. We can generate margins from that business, we more than welcome that volume continuing to strengthen. You know, in terms of Medicaid redetermination, it's early, it's premature to draw any, you know, specific long-term conclusions at this point. Several of our markets have begun the redetermination process. Arizona started in April, Florida started in May, and Texas started in June.
I would tell you, we have not seen any noteworthy positive or negative trends. We have not seen any significant increase in our uninsured volumes. We haven't necessarily seen any significant increase in Medicaid pending, where someone comes in, and we determine that they don't have Medicaid coverage, and then we try to get them qualified for it. We haven't seen any significant trends there. We I know that, you know, CBO came out with a report recently about individuals who have double coverage, you know, Medicaid coverage as well as commercial coverage, maybe through their employer or their, their partner's employer. You know, we've been tracking that on a daily basis, and we really haven't seen any significant volumes of, you know, people coming in with, you know, double coverage at this point.
The next two of our larger states that begin the redetermination process, is California and Michigan, and that'll start in July. You know, we obviously will continue to track that and keep everyone updated. You know, there was some, you know, information that, CMS released, recently in terms of the, you know, the state process, and, you know, are they going about it in the most appropriate manner? So we'll see. I mean, it's early and, but at this point, nothing significant, either way. That's how we assumed it. That's what we assumed in our guidance-
Okay
for this year.
You mentioned Conifer and the role it'll play in navigating redeterminations. Can you elaborate a little bit more on that? Does it present in a differential position?
Yeah, one of the things that Conifer has long had is a, is an Eligibility and Enrollment service as part of the end-to-end offering, really in the front end of the revenue cycle. By working, in particular, across multiple entities in the states that we're in, we've really honed the ability to actually take and support enrollment efforts, both on the outpatient side and when patients, come into the inpatient setting and appear to not have coverage. We have a very rapid eligibility determination process that prevents the leakage of that case moving out of the environment before determining if they're eligible for enrollment. For hospital system clients, this can be very beneficial. It also obviously helps the physicians that are taking care of them to not have it be a situation where the patient may be uninsured for their own professional billing.
The client is typically the hospital, and what it allows them to do is identify eligibility during that hospital stay so that they're able to bill and collect for that. The Medicaid side of that just requires really understanding the Medicaid enrollment processes state by state, which we have a lot of expertise in, given the Conifer client portfolio. The exchange side of it is more unique because you can support helping the patients to make the right choice for them on the exchanges. As everybody knows, the mathematical thesis around redetermination sits kind of on the exchange enrollment for those that are disenrolled. We think that that portion of it, the two combined, but the exchange portion of it, which is pretty unique, will be very helpful.
Okay. Let's go to reimbursement rates. I mean, everyone's getting a little bit better pricing on the commercial side. I guess there's two things I'm looking for here. First, are you still in the process of going through contract renegotiations, and so the momentum you're seeing in terms of rates, should build throughout the year? You know, second, how do we think about the next three years and the escalators that are embedded in contracts that have been renegotiated in this, you know, higher inflationary environment?
Yeah, well, we're always going through contract renegotiations with the payers. I would say that we're very well contracted at this point, almost 100% contracted for 2023, the mid-80s, you know, for 2024, and even pretty substantially contracted for 2025. One thing that's important, more recent negotiations, the rates we've been able to negotiate a little bit stronger than historical levels. You know, when we think about going down the road, one thing that's important to keep in mind is when we negotiate contracts, typically long-term contracts, three, maybe four years, and we, generally speaking, negotiate annual rate escalators, where you get X% increase year one, and then another X% increase year one, another increase year three.
It's not like we negotiate a one-time rate increase, and that rate stays the same for the entire three,four -year period. Obviously, as inflation comes down, that'll be beneficial because we have built in, you know, rate escalators negotiated with the health plans.
Those escalators sort of reflect this higher inflationary environment, just, you know, to say it clearly.
I mean, I just think, you know, again, no plan is coming and saying, you know, "Here's what CPI has been for the last year and a half, and therefore, this is what we're going to do." I think as Dan put it, the rates are better than what we were getting in the past. More important, you can't separate management of the rate in the contracts from the management of your largest cost line item that's subject to inflation, which is labor. We really take the two hand in hand and say, "It's our responsibility to manage both in order to be in a position where we can provide some predictability about earnings growth." If you look at...
This is why we've been so focused on, you know, being best in class on labor management, because you can't offset all of it through rate. But the combination of the two, especially as our SWB, as a percentage of net revenue, has been very well managed through an inflationary environment, through our initiatives and length of stay, productivity, contract labor reduction. The two of them put together, as I said in my opening comments, give us a better, more tangible sense that as we move the dials on the knobs, we have a better ability to predict than during the pandemic, what will happen from an earnings perspective.
Let's go to the labor environment. We'll start with contract labor. What are you seeing there just in terms of utilization? You've mentioned now that rates are at, you know, these lower levels, you know, it's not as burdensome to take on contract labor to support the volume growth. Just what are you seeing on the contract labor front in your utilization and rates?
We've continued to see moderation in the bill rates. You know, we're part of that in terms of negotiation. We have continued to see some moderation, and we would anticipate that to continue as we move through the year. That's how we, you know, build our guidance under that assumption. Utilization, we've been able to reduce utilization in many cases. Our recruitment and retention efforts have helped to increase our full-time employed staffing, which certainly helps. We've been very clear that, you know, we do not anticipate our contract labor as a percentage of total SW&B to return to pre-pandemic levels. Before the pandemic, our contract labor was roughly 2%-3% of SW&B.
In the fourth quarter, it was a little bit north of 7%. We brought that down to 6% in the first quarter, and we would expect there to be continued moderation. We won't be back to, you know, the 2%-3% territory by the end of the year. We've been very transparent, and we don't. At this point, we wouldn't think that even next year we would get back to 2%-3%. Obviously, we're working towards, you know, we're continuing to reduce it, but we're not assuming we get back to 2%-3% in 2024 at this point. Very good progress. The team is really managing that labor spend very, very effectively.
That's helpful. On the full-time employment front, probably the more important piece long term, what's the right way to think about sustainable wage growth? We're all familiar, it's a very tight labor market. Does that just structurally mean we're in for higher wage growth over the next, you know, two to three years?
I do think that, to your point, even around contract labor and the longer-term improvements, are more likely to come from the reestablishment of a permanent workforce than they are productivity management and other things, right? The nature of the initiatives are very much changing to recruiting and retention and even, you know, thinking about alternative and new nursing models and extending some of the capabilities there from that standpoint. The supply and demand environment for certain things, in particular, more high-end nursing, right? If you're in a high acuity strategy, you're going to have to have higher-end nursing. You can't just take a new grad and put them in that environment. You have to train them to get there.
The, in particular, OR or cath lab technicians or others, yeah, there are real shortages there, and I anticipate we'll see a little bit of inflationary pressure more than just this year. You know, as we've said, we're managing that pretty well. I mean, if you really look at the labor inflation on a unit basis, it's, you know, been a percentage point, percentage point and a half, a little bit more than the usual, but not, you know, incredibly excessive. You have to create a good work environment people want to stay in, and we can always be better at that, but we're working hard at it today.
Okay. Let's go to the ASC segment for a moment. You know, last year, you acknowledged you had pretty aggressive targets. You were hitting them at some periods during the first half of the year. Third quarter was a little more challenged, that you brought down guidance. Since then, first quarter, you beat and took guidance back up to kind of where you were last year. How should we think about, you know, the long-term drivers, the long-term sustainability of the type of, you know, guidance you've got in place for this year for ASC?
Yeah, I know, and I appreciate you're asking the question that way. I mean, the reality is, the way to look at the USPI business is long term. That is the most important two words that you raised, because last year there was a bit of a choppy environment. We had made assumptions, you know, about no impact of COVID. Frankly, our guidance is 4%-6% EBITDA growth. We hit 4.6%. Like, this should not have been as much drama as it was, except for the fact that we had higher expectations for last year. Obviously, we have high expectations now for this year, to your point, in terms of our raise. The environment feels more stable. You know, as I indicated in my opening comments, many of the fundamentals that we look at are positive.
We indicated in the fourth quarter, you know, to Dan's point, about multiple months of momentum, we indicated at the end of the fourth quarter last year that we had added physicians on a net basis for the year. I think there was concern that we hadn't, right? Which was some of that Q3 issue. The fact is that we had, and that gave us confidence to come out in 2023 and say, "Regardless of the impression of that third quarter in 2022, we're confident about this year." Now, we've had a chance to look at first quarter. We've added even more physicians, you know, to the environment at USPI over prior year in the 1st quarter. We feel good about the fundamentals there. Long term, this business has a terrific tailwind. We have a great service mix.
Because of the margins we generate, we are the preferred partners for physicians, right? If physicians are interested in an operating model that will help them diversify their centers, do it at very high margins, and have a USPI business development support to grow their center, that package works very well in terms of growth. From an M&A standpoint, the pipeline looks great, you know, we feel very good about the access to high-quality assets that we're at the table for looking forward. You know, we're very comfortable with the fact that on a multi-year basis, as we look at each year's vintage, those multiples are getting driven down on a post-acquisition basis, you know, below 5x and 6x pretty consistently. We think there's a lot of runway for USPI. The way to look at the business is long term.
Its ability to generate free cash flow for Tenet as we grow it and allow us to pursue self-funded acquisitions, right, and allow us to pursue further deleveraging of the company, is really a strength of our business going forward.
I think last year, I think it was the third quarter, you talked about a facility in, like, Tennessee, or I'm forgetting the details, where you replaced a lot of low acuity with orthopedic, and so volume was down, but, you know, revenue was up, and I'm forgetting the numbers. How much is that kind of pressuring, you know, how much of that is happening within the 3%-4% where, you know, you're seeing really good mix shift, but, you know, it's not coming through on the volume piece?
Yeah, as I said, we're still gonna continue to do what we think is the right thing from a service line standpoint, regardless of the volumes. You know, I indicated in the first quarter of this year, with a lot of our service lines growing, some of the low acuity work that we were looking at has been flat. One thing about first quarter growth, it wasn't that we just invited a bunch of low acuity work back. We're still gonna focus strategically on what we think is right for the business, but that area did not grow. That's indicative of the fact that we're continuing to pursue what we think is right regarding those service lines.
We're not gonna stop doing that because it's the right thing for the health of the business, the growth of acuity, the margin profile, and in particular, the value we bring to the payers in the USPI platform.
I guess that brings me to something I've struggled with a little bit. I mean, the revenue per case growth, you know, in this 2%-3% range, you know, that sort of looks like what rate growth is, and so it doesn't feel, in those numbers, like, you know, there's this acuity mix happening. Can you help, you know, tease out what's happening within revenue per case and how much is rate versus the focus on acuity?
Similar to my point earlier about, you know, the hospital net revenue per adjusted admission being influenced or, and impacted as lower revenue-yielding procedures grow, you have the same dynamics in the ASC side, where as certain procedures, such as GI, continue to strengthen further and recover further from the pandemic, that has an impact, mathematically, on the net revenue per case metric. Just similar to the hospital net revenue per adjusted admission. We feel very good about our contracting position with our ASCs, and our focus on the higher acuity services and USPI, orthopedic, et cetera. We feel good about our pricing yield as we look out over the next two to three years.
Okay.
Yeah.
Oh, do you have something?
Well, I was just gonna say, I mean, you know, just to make it very tangible, I mean, sometimes the reimbursement for one of those lower ASC-appropriate, lower acuity procedures, GI or an ophthalmology case, I mean, could be a tenth or a fifteenth of what a joint reimbursement would be, right? The mathematics work out so that what we really look at is the growth rates of our high acuity procedures. That's why, you know, we follow our joint cases, for example, which is a really important growth area for the future in ASCs, and including things from HOPD that will move into the ASCs and double-digit growth in those areas. We feel very good about the fundamentals from that standpoint.
Okay. Can you talk a little bit about where you are on the M&A side? This is obviously a big piece of the strategy, allocating disproportionate dollars to USPI, and M&A. You've announced a large acquisition, like, each of the last three years or so. Where are you in just in terms of the pipeline and what you're seeing on the M&A front?
The M&A pipeline is very strong. As I've indicated before, the benefit of USPI's connection to Tenet is that we have multiple avenues for growth, right? There are lots more... As the economy and the health systems recover, we have the benefit of, you know, the leading brands, 50 health system partners, that are also looking to expand and develop in their markets. There's a pipeline that comes from that. There's obviously an M&A pipeline that comes directly from what we do with USPI. We've indicated, importantly, we have well over 20 de novo projects that are in the works, so those are startup facilities, that are important.
you know, not surprisingly, many of the medical groups that are receiving private capital infusions, in their own structure as they scale up, those are attractive groups to partner with. They look at USPI as a preferred partner to scale with, because under our ownership and management, in particular, connection to Tenet, the returns on those ASCs are better than any other ASC company can give. They're putting capital into one segment of the business, we partner with them to put capital into our segment of the business and grow. The diversification of opportunities helps us have enough opportunity for high-quality assets. We get inundated with stuff that's not quite high quality, and we're very disciplined about assessing and diligence, those types of things and avoiding those that are, you know, not as high quality.
We pass on a lot of stuff, too.
On the de novo side, I mean, why couldn't 20 be 40 or 50? I mean, we're all familiar with all the tailwinds of ASC momentum, all the volumes going to the ASC setting. When you look across your markets, is it that there's plenty of capacity in other markets, and so you have to wait for the market to catch up? I mean, just any color on.
Yeah, this is a matter of how you think about timing on de novos, right? Obviously, there are startup de novos that you bring together the partnership, syndicate the asset, and move. Many physicians like to do that on their own, and so you have startup ASCs, oftentimes single specialty, and they'll bring it so far, okay? Then they'll say, "Okay, now we want a partner who's gonna get us more synergy, more growth opportunity, teach us how to make it multi-specialty from our single specialty, and maybe even deploy capital with us to add 2 ORs," or something like that. There's kind of that, for lack of a better description, 18 month-36 month window in startup ASCs that we can acquire in before their full earnings potential.
By the way, that's some of the basis of the second part of the SCD partnership as well, right? I mean, we have opportunities in that time range. Of course, there are always gonna be de novo centers that mature more fully, that become available, where it's simply a matter of synergy, and there's senior physicians that may be leaving. One of the things about USPI's operating and management agreements is we have very good protocols for how to turn over equity when people leave, to bring new people in and allow them to participate in the equity, and so we can help refresh partnerships at that stage.
As long as you can play along that time continuum effectively with a good value proposition, you can pick up things at different stages, even if every single center is not a USPI de novo.
Okay. Dan, probably for you here. Margins, I mean, we're seeing some recovery in sort of the not-for-profit world after, you know, pressures last year. It seems to be like we're in an environment where it's conducive to a little bit of margin recapture from the pressures over the last couple of years. What's your sense of just the margin environment and specific to Tenet with the mix shift of the ASC business and, you know, slightly better reimbursement? Do you think you guys are in a position to improve margins over the next couple of years?
We do. We've obviously made significant improvement in our margins over the past four or four years through further efficiencies in our acute care portfolio from a cost perspective, labor management perspective, focus on higher acuity, higher revenue-yielding service lines. The growth in our USPI business, we got, you know, USPI margins approximately, you know, 35%-40%. Incredibly strong margins. We're gonna continue to invest capital to grow the business. We think there continues to be margin improvement opportunities on the acute care hospital side. Conifer's margins have improved roughly 1,000 basis points, you know, over the past three or four years. Their margins continue to hold steady. You know, it's what we did, I mean, continue to focus on, you know, strengthening our margins.
The one.
Yeah
... additional comment I'd make there is that we do believe, in particular, with the, you know, premature mortality that we saw from COVID, right? That would've sort of been actuarially spread over maybe a five-year period that happened upfront. As that population, the aged population, chronically ill, you know, within five years, again, of their own mortality, repopulates, that is a natural tailwind for the services sector. One of the reasons we've focused our time during the pandemic on making our chassis more efficient is because, as Dan said, we welcome that Medicare population back into our environment, 'cause we can do it and generate a margin. We're looking forward to seeing that repopulation, and that's a tailwind that we think will benefit from a margin perspective as much as a volume perspective.
Okay, perfect. Well, with that, I think we're out of time.
Thank you.
Thank you, Tom, Dan, and Will.
Thank you very much.
Thank you.