Assume, and in fact they have been, sort of moderating throughout 2023, and we assume they'll continue to moderate. Now, as you point out, 2024 started strong. It doesn't appear like there's a lot of moderation early in 2024, but I don't know that this really is something that can continue for the next three years at this level. So we can debate, is this going to slow down in six months? Is it going to slow down in 12 or 18 months? And again, I can't guarantee that it's going to slow down at all, but it just feels like, based on what our historic experience is, that at some point this is going to slow down and we're going to see some of these deferred and postponed procedures kind of exhausted and return to more historic norms.
Got it. Another hot topic in the last couple of weeks has been the Two-Midnight Rule or the clarification for MA plans, primarily because Humana mentioned it on their call as seeing more short-stay inpatient admissions and fewer observations. We threw a bonus question in our monthly hospital survey to see if the nonprofits at least were expecting a material tailwind, and 90% said they expect an immaterial benefit, so a benefit, but they haven't called it material. United, as we've seen transmittal United put out to providers, "We're not changing anything." I think Aetna and OneMarket did the same. So how are you guys thinking about this? Are you seeing much on observation versus short-stay? I feel like we've backed up in time 10 or 15 years. The last time this was really topical, but how do you think that impacts 2024 for you guys?
Yeah. No, look, so again, I think you put it in the appropriate context, Gary. So there was much debate 10 years ago, let's say, about how to properly characterize patients as either inpatient or observation, and Medicare adopted the Two-Midnight Rule rule as a guide to essentially say time matters here, and if a patient is in the hospital for two midnights, that's sort of compelling evidence that they're likely to be an inpatient. Now, you still would have to prove that their stay was medically necessary, etc., but the lapsing of the time was important from Medicare's perspective. And in fact, the Two-Midnight Rule has really applied to traditional Medicare patients for the last decade or so.
We, meaning the provider industry collectively, always had the view that it ought to apply to the Medicare Advantage industry as well, although the payers always resisted that, saying that CMS had never said that explicitly. Well, CMS has now said that explicitly effective January 1 of this year. But again, the interesting thing is Humana suggesting not only was that going to have an impact in 2024, but they suggested it had an impact late last year as providers started to bill more inpatient procedures, etc. I can't speak for providers writ large, but for us, I don't think we've changed the way that we bill based on what we think patients meet inpatient criteria. If they do, we bill them as inpatients. So I sort of ultimately agree with the survey results. I think we feel like this should be incrementally helpful to providers.
As we appeal and as we debate and argue with our payers over whether somebody qualifies as an inpatient, we certainly now can point to CMS's somewhat more aggressive stance that the Two-Midnight Rule has to apply to all Medicare patients, both Medicare Advantage and traditional Medicare. But I think we remain cynical about how willingly payers will comply. So yeah, this can't be anything but a good thing, but I saw some estimates that this would increase provider revenue by 3%-4%. That, I think, is not.
I've seen industry numbers, 15%-20% of patient days are observation days. Do those numbers make sense to you?
Yeah, I think that's about right.
Okay. I want to go to physician subsidies, which was kind of the surprise expense for 2023 once we got past all the COVID-driven temp labor increases, quadrupling of hourly fee. Then we kind of thought we were past the surprises, but physician subsidies really went up a lot in 2023. But what I want to ask about was, in the third quarter, you thought those expenses might be up 30%-40% for 2023, would moderate but still go up 10% or 15% next year. But on the fourth quarter, now you're saying more like an inflationary rate, which I guess means mid-single digits. So how did that swing so quickly in your favor? How are you making progress on that?
So yeah, I think to put the issue in context, I'm going to say that it really began in the back half of 2022, where as a result of the No Surprises Act, as a result of, I think, greater, more aggressive posturing by payers with these hospital-based physicians. And hospital-based physicians, I think in this case, mostly for us, were anesthesiologists and emergency room physicians, a little bit of radiologists. But we were having those groups who generally we have contracted those services out. Those groups were coming to us in late 2022 and saying, "Look, you've either got to you've got to pay us higher subsidies because we're making less money as a result of these dynamics, or else we can't continue to provide the service." And our reaction was, in some cases, too, just simply pay higher subsidies to our incumbent providers.
In other cases, we put the service out for bid through an RFP and brought in another provider. But in any event, we were always paying higher subsidies. And in some cases, we were just bringing the physicians in-house, hiring them, running the service ourselves, but again, at the end of the day, at a higher cost. I think what we found, and I think you sort of described it, is that most of these arrangements were reset by us by the end of 2022 or the beginning of 2023. And so we saw a dramatic increase in physician subsidy expense in 2023 over 2022. It was about a $120 million increase, but pretty radical, pretty much $30 million a quarter over the course of the year. And so as we get into 2024, I think our view is, "Look, these arrangements have largely been reset.
They've been stabilized at a level where the providers of the service can make a reasonable profit at the increased subsidy level," etc. It just feels a lot more stable to us. Now, again, to your point, look, this came up as a surprise late in 2022, early in 2023. It could be more volatile, but we're just feeling kind of a little more confident that this is the whole environment for these hospital-based physicians has stabilized some. So that's and our view of that, I think, has improved from Q3 into Q4 and into our guidance.
How do you characterize the level of insourcing activity you've done around those two specialties?
Yeah. So I mean, insourcing, certainly for us at least, has been our strategy of last resort. So I would say of our 27 or so acute care hospitals, we've insourced maybe three or four of them. And I think our view is to continue to outsource where we can and put these contracts out for bid. There do seem to be providers out there that are competitive and aggressive and willing to do this at a more efficient rate, etc. So the hope is that over time, we can wring some greater efficiencies out of this after obviously having ramped up to a much higher expense level.
Another new acronym for 2023 for a lot of people was DPP, so Medicaid State-Directed Payment Programs. Excuse me. Historically, we might have called those UPL programs. UPL programs are just supplemental programs, etc. But the question is around just how much growth we're seeing. Investors wonder how sustainable that is. You're going to see from all your supplemental programs, I think, almost a $180 million pickup year-over-year heading into 2024. Somebody asked me last week, "They see the total net benefit from these programs they're expecting in 2024 is $800 million," and they're like, "Well, that's 40% of the company's EBITDA, so that's problematic." I think Medicaid as a category, you'd still say you lose money on Medicaid patients even with the benefit of that $800 million, but I'll let you correct me if I'm wrong.
So my thought is you don't look at the $800 million in isolation any more than you would look at a big contract from United if you just took the revenue out or whatever in isolation. But maybe the question is, one, how do you look at the Medicaid payer class in terms of its profitability? It's obviously very different for acute than behavioral. I guess I'm talking more on the acute side. And then I want to get into just what you think about the sustainability of the funding.
Yeah. So a lot to unpack, but I'll do my best. So first of all, I will say that these Medicaid supplemental programs, and to your point, we now put them in our disclosure all under these sort of Medicaid supplemental programs. So that includes the DPP. It includes UPL. It includes this reversion and share. I think that's the right way to think about it and to look at it. They impact both our acute and behavioral hospitals. With the new Nevada monies, I think about 60% of our Medicaid supplemental payments are acute and about 40% behavioral, but they certainly affect both businesses.
The states, I think it's worth pointing out and highlighting and stressing, the states implement these programs not to just sort of sprinkle manna from heaven around to providers, but I think very much directly as an acknowledgment that their historic Medicaid reimbursement has been inadequate, especially for those hospitals who are providing the bulk of treatment for Medicaid patients. The states do it with these supplemental programs because these supplemental programs attract matching federal dollars, and so they're sharing the cost with the federal government. We probably have disclosed in more detail these Medicaid supplemental programs and their details than anybody else. If you go back however far you want to go back and sort of kind of track the disclosure over years.
They've never come down.
They never come down. They've been going up. Within individual states, there can be some up and down from year to year, but the programs generally have an upward trend to them. And I think it's because, particularly the safety net hospitals or any hospitals that rely on or treat a large number of Medicaid patients rely on these things. And it's very difficult, I think, to take it away because I think if you take it away in a material way, you can tweak it or you can reduce it by 5% or something one year to the next. But if you take it away, I think many of the hospitals that provide these services simply become not viable financially. And that, I think, is a public policy outcome that neither the states nor CMS are willing to tolerate.
The other point, which I think you make, and I think you make a good point, is I think it's not appropriate to just sort of carve this out of Medicaid reimbursement and say, "Well, this is 40% of your EBITDA," any more than it's appropriate to take Medicare disproportionate share or Medicare outlier payments or any aspect of the Medicare program and say, "Well, this is X% of your earnings because Medicare " and I think hospitals who receive Medicare payments are going to view these as kind of holistically part of what the necessary reimbursement is. So again, I think that there's certainly the risk that individual states can tinker with this.
Certainly, CMS has talked about capping these payments and controlling them, not really eliminating them, but they've acknowledged that they've grown very, very quickly, and they're sort of trying to slow the pace of that growth. I think all that is entirely possible. But in the meantime, and I think I made this point on our earnings call, we know half a dozen different states and geographies that are entertaining new programs, etc., that at least at the moment, it doesn't appear like they shouldn't be able to go through if they're structured properly, etc. So while we acknowledge that we are receiving a lot of these payments, and we acknowledge our peers are too, I think the number that HCA is now up to in these Medicaid supplemental payments is close to $4 billion. So they're become an important part of the reimbursement landscape.
I can see them being tinkered with, but I can't see them being eliminated or materially reduced.
Because on the acute care side, on the mid-surge side, is a Medicaid inpatient admission, even with fully baked with supplemental payments, is that still an unprofitable, fully loaded case?
Yeah. So again, certainly, Medicaid I think we would argue that any patient who has insurance, whether that's Medicaid, Medicare, or commercial, is a patient that we're generally going to still have being profitable, but.
Marginal.
Marginal, yeah. Commercial patients will be the most profitable, then Medicare, then Medicaid. And obviously, the state and the reimbursement level will affect that Medicaid reimbursement. But the way we really sort of look at it is incrementally, Medicaid patients can be very profitable because the incremental cost of treating a Medicaid patient is relatively low, and as long as the reimbursement is reasonable. And that's always, as you know, been the model for this business, is the incremental cost of that extra patient, etc., is relatively low, and that's where you're going to make your biggest margins.
Are there any mechanics to DPP that we should be thinking about? Once upon a time, my mind's eye, we call these bed taxes, and literally, it was hospital inpatient beds constituted what you paid into a pool, which created matching funds and came back. And then I think there's a lot that are based on Medicaid days, so your Medicaid patient days. Now it looks like maybe there's some that are actually based on revenue. But as redeterminations go down, let's say the Medicaid population is in the process of shrinking by 15%, do just the absolute dollars, both the revenue and the taxes, come down to you ratably, or is there any other, is there some lag with that, or is there some other mechanism that we should think about, let's say, for 2025, 2026 if you have a smaller Medicaid population?
Yeah. So I think, again, you're on target by saying that to the degree, most of these programs are based to some degree on Medicaid utilization, whether that's days or revenue. And so to the degree that Medicaid utilization goes down in favor of commercial, etc., commercial exchange or whatever, then in theory, your exposure to these programs go down. Now, they'll do so with a lag. To your point, usually, these programs are based on data that's a year or two or three old, so it's not going to be all that immediate.
I think, again, the way we tend to think about it in sort of a very broad way as we're doing our projections over the next few years is that we're likely to get some new states, some new geographies that will help to bolster this reimbursement and probably offset you suggested a 15% decline, which seems pretty hefty to me, but we'll see. We'll see. But I think, again, these changes are likely to take place, I think, incrementally over the next few years. And I think the combination of some pressure from reduction in Medicaid days offset by some of the newer programs should make this still likely a positive over the next few years.
I want to lead into just behavioral pricing, which has been strong for the last few years for you. Some portion of that is this DPP that's coming into the behavioral side. So you can see that in the Medicaid revenues for the behavioral business. But also just on the Medicaid side, the bulk of what you're getting paid is from Medicaid managed care organizations or the states like farm that out, so you're negotiating rates there. How much does your sort of sustaining your rate of behavioral revenue growth or pricing growth depend on DPP or has been dependent on DPP or is dependent on that going forward?
Yeah. I mean, again, as I said, 40% of the Medicaid supplemental payments today are going from behavioral. Some of these have been in place for some time. States like Texas and Florida have had their programs in place for a long time. States like Kentucky are only a couple of years old. And obviously, the newest state for us from a behavioral perspective has been Mississippi. I think the bigger issue, quite frankly, that it's contributed to the strength of our behavioral pricing, and we've talked about it at some length, is we've gone back in our contractual negotiations to some of our managed Medicaid payers, especially, who are amongst our lowest payers.
In an environment of, I'll call it, bed or capacity scarcity where we're turning patients away because we don't have. It's generally not a shortage of beds, but it's generally a shortage of staff, we've gone to our lowest payers and said to them, "Look, everybody else in this market is paying, I'm making this up, $750 a day. You're paying us $700 a day. If you're unwilling to bring your rates up to $750 a day, we're going to simply terminate this contract and admit other patients who are willing to pay us $750 a day or who insurers are willing to pay us." And so one way or the other, honestly, we don't always get the payer to pay us the increased rate. But one way or the other, we cancel the contract. We admit patients who are paying us that higher rate.
As a consequence, our behavioral pricing, which has historically been kind of in that 2%-3% range year-over-year, has during the pandemic run often above 6%. But one of the dynamics we're facing going into 2024 is some of those renegotiated contracts have now been in place for two or three years. So we're starting to anniversary some of that benefit. We're continuing to look at other low-paying contracts, but we think some of the lowest-hanging fruit has been sort of recognized there. So again, over time, I'm not sure it's going to be immediate, but over time, I think we're likely to see some moderation in that behavioral strength.
Last 30 seconds here on commercial rate negotiations on the acute care side of your business. I mean, generally, the thesis has been historically, you see those rates follow inflation. So if you're seeing clinical labor cost inflation, eventually, hospitals with share are going to be able to get that reflected over time into commercial pricing. Is that simple thesis intact for you or anything you would attach to it?
Yeah. No, I think that's largely true, Gary. I mean, I think we've said that beginning probably about the middle of 2022, when it became apparent that inflation was elevated and likely to run at an elevated rate for an extended period, we started to, as we renegotiated our acute care contracts, get rates that I'm going to say were 150-175 basis points higher than they had been in the last few cycles. So I think that's likely to continue. I think providers are trying to recoup some of that additional physician expense that we talked about earlier in some of their contract renegotiations, etc. But yeah, I mean, I think generally, there's probably, at least from an inflation perspective, another 12, 15, 18 months to run on renegotiated contracts and getting sort of greater inflationary increases.
Great.