A couple of weeks ago, there were a number of Republican congressmen and women who commented that even though the bill contained a significant amount of Medicaid cuts—and, and I think worth noting that they were very sort of generic, non-specific Medicaid cuts—but, a number of congressmen and women, including some fairly conservative, sort of those described as MAGA, you know, members, suggested that they only voted for the bill because they were promised by their leadership that there really wouldn't be significant Medicaid cuts. We do know that, you know, beyond that, obviously, you know, any bill that gets passed or, or has to be reconciled with the Senate, and the Senate is probably even less enthusiastic or seems to express less enthusiasm for big Medicaid cuts.
That seems to be the context that everybody's operating in, meaning, the Republicans are certainly aggressively looking for ways to fund the tax cuts, extensions, which they, you know, very much want to pass, but at the same time are trying to do so in a way that, I think, is not terribly disruptive to the healthcare system, etc. I think there's a recognition, at least among, I think, members of Congress and the Senate who really do understand the system, that significant Medicaid cuts would be, I think, quite disruptive. As you know, there are a bunch of sorts of, you know, I'll call them menu items, you know, on the table about, you know, how, you know, DPP programs could be ring-fenced, their growth could be slowed.
Some of the bigger sort of Medicaid cut alternatives like FMAP and rate caps seem to have been taken off the table, though they sort of sometimes, you know, kind of get back on. We'll see. I mean, I think the expectation on, you know, our part, and, you know, I always say we don't, you know, profess to have any greater insight or understanding or predictability than I think anybody else does. The expectation I think that we have is that any cuts in whatever form they're in are likely to be sort of more incremental than dramatic, more incremental than draconian, likely to be over an extended period of time. That certainly allows us, you know, more time to react and manage through, etc. You know, the hope is obviously there's more clarity.
I don't know if that's in the coming weeks or months, you know, but, you know, sometime there's more clarity. In the meantime, you know, as we, I think, articulated in our earnings call just, you know, recently, I think fundamentally we feel good about our two businesses. I think we feel probably they're more predictable, they're more steady and solid than they've been in the number of years probably since the pre-pandemic. For the most part, you know, the message that we convey to our, you know, own folks and operators is we can only control the things that we can control, and we should do that and keep our heads down and operate the business as efficiently and appropriately as we can.
Speaking of things that you can control, like, should we see Medicaid cuts, what sort of levers are you contemplating that you have at your disposal to potentially offset the impact?
You know, what I've said to people is I think, you know, the most recent, you know, playbook, and it's certainly not perfectly analogous, but, you know, at the beginning of the pandemic, you know, back in March, April of 2020, we, you know, implemented a whole series of initiatives to respond to, at the time, what was a dramatic decline in volumes, and demand. And, you know, we had some pretty significant layoffs, and we cut our overhead costs, and, you know, we froze wage increases and, and 401(k) matches and paused our dividend and reduced our CapEx plans. You know, and all those things I think are on the table now. It's a little bit different with Medicaid cuts because in theory the demand doesn't change, but, you know, just the reimbursement changes.
I think it's an example at that time, you know, I think here we would have a lot more time to react. It'll be a little bit more deliberate. At that point, you know, we were literally, you know, making these changes in real time and on the run. Yeah, I mean, I think we've always shown that we can be flexible, we can be nimble, and prepared to do so once we kind of know what the playing field really looks like.
Great. Tariffs are another issue currently being contemplated by the administration. How do you think about that risk for your business? Do you have enough visibility into where your supplies are sourced to measure the potential risk there?
The challenge in trying to evaluate the impact of tariffs is, I think, several-fold. I mean, one is, as you know, tariffs and who's being, you know, tariffed and charged changes, you know, daily or, you know, maybe a little less frequently, but it's pretty, pretty fluid. That is a challenge. Secondly, as you suggest, it's difficult for us to know a lot of times when we're buying supplies, which I think is the main thing we're talking about, you know, where they're necessarily manufactured, and they may not be manufactured from the place that's delivering them or, you know, the components may be manufactured elsewhere. That is a challenge.
I think the protection we have in when we think about tariffs and its impact on our supplies is that something close to three quarters, maybe, you know, 70% of our supply purchases are made under multi-year contracts, either through our group purchasing organization or through contracts that we've negotiated separately with manufacturers on our own. Most of those contracts really don't, you know, they provide price protection, you know, against, you know, cost increases of any kind. You know, some do not, but I think most do. I think the notion is that, if the tariffs begin to have a significant impact, it's unlikely to flow through to our business in a material way, at least this year. You know, maybe into next year, we would continue to be protected under some of those contracts.
Don't view that perhaps as an immediate risk as maybe some of this other stuff that we're talking about.
Got it. That's helpful. Maybe lastly, on the regulatory front, site- neutral reform, there's a handful of proposals out there that range in scope and impact. What are the key items that you're monitoring in terms of potential proposals and what you, what the unintended consequences of some of the more serious proposals might be?
Historically, I think the biggest potential impact to us from site neutrality reform would be in our freestanding emergency departments. We have about 30 of those currently and, you know, another 10 under development. Those operate, for the most part, as, you know, as they're described, freestanding emergency departments. They operate as if they are an emergency department out of the hospital, or, you know, excuse me, they operate as freestanding. If they were reimbursed as an emergency department of the hospital, they would be reimbursed somewhat differently. Now, in most of the site neutrality bills that have been bandied about over the last several years, FEDs or freestanding EDs have been excluded.
And, you know, the hope or the expectation perhaps is that they would be excluded in any sort of current bill, but that would be the biggest exposure to us. Again, I think, you know, at the end of the day, even if they were to be included, I don't know that the impact on our earnings would, we would describe as material.
Great. Let's move on to the more fundamental operations of the business. The 2025 guidance was stronger than expectations despite excluding some of the new Medicaid programs in Tennessee and Washington, D.C. The segment-level component seemed to point to 6-7% EBITDA growth, but the guide has optionality into the low double digits. Can you help us understand why you decided to extend the range at the high end? What needs to happen to achieve that?
As I was alluding to before, I mean, I think that the forecast and the underlying metrics in the forecast and in the guide in 2025 return us to mostly sort of historically normative levels and assumptions. You know, what we talked about was mid-single-digit revenue growth for our acute care business in the 5-7% range. If you pick the midpoint, say 6%, split pretty evenly between price and volume adjusted admission growth, that's pretty consistent with what the business has run historically. The behavioral side may be a little bit, you know, more aggressive, you know, maybe 7% at the midpoint, split between, you know, volume growth of, you know, patient day growth, 2.5-3%, price 3.5-4%, something like that. Again, those metrics in both divisions, I think, are pretty historically, you know, reasonable.
I think we've talked about the fact that, you know, I think particularly on the behavioral pricing side, I think that's particularly conservative given where we've been running in the last several years. The reason I think we tried to give maybe perhaps a broader range of, you know, ultimate earnings and, you know, EBITDA earnings was the things that we talked about earlier that, you know, if there are some incremental changes to the forecast as a result of reimbursement changes, expense changes as a result of things like tariffs, etc., that we would hope that the impact, particularly in 2025, would be incremental, and small enough that we could sort of absorb it in that range of guidance that we've given.
Obviously, if there are really more dramatic cuts and they really are more impactful and more quickly impactful than, you know, we might be, you know, expecting at this time, you know, we, we'd have to reforecast. The notion was to give us a little bit of room, a little bit of cushion, so that some, some of these unknowns, depending on how they played out, we could absorb in our, our existing guidance.
Great. Let's talk a little bit more about the behavioral volumes. You're targeting 2.5-3% patient day growth, I think, in 2025. You know, that sounds like an achievable target, but when I look back over the years, that level of growth has been somewhat elusive. Why has that been the case for an industry that seems to indicate structural supply-demand imbalances?
I think there's a few reasons. I mean, probably the single biggest reason, especially during the pandemic, and sort of to your point, it's been an elusive target, I would say, over the last several years. For many years before the pandemic, 2.5-3% growth in patient day growth in behavioral would have been considered relatively modest, you know, based on our historical experience. I think the reason it slowed, there were a number of reasons it slowed during the pandemic. Probably the single and foremost reason was a labor supply and demand disconnect, meaning we struggled to hire all the employees and staff that we needed to treat the patients who were being presented to us.
That's mostly, I think the shortage was mostly in the nursing component of our, you know, workforce, but it included things like therapists, and it included, quite frankly, some non-clinical or non-professional folks like mental health technicians, etc. The main driver of that, the main reason that we struggled along with other subacute providers during the pandemic is that we saw a great number of our own staff, nurses, but others, other clinicians as well, leave the subacute environment, the behavioral environment, to go work in acute care settings during the pandemic where they were able to, you know, really make, sort of had an opportunity to make extraordinary premiums over their regular salary.
I think as the pandemic ended and, you know, obviously COVID is still with us, but as the COVID surges have ended and it's become less of an issue, a lot of those folks have returned to our employee and to full-time employment in our hospitals. It's not as much of a stretch. If you look at our patient day growth, while we didn't hit the 3% in 2024, it has grown. It grew, I think we were around 1.6% in Q1 of 2024, 1.9% in Q2, 2.2% as I recall in Q3. We were averaging 2.5% or so in October and November. Things really fell off in the back half of December, which I think was largely a function of the calendar and how the holidays played out at the End of December.
Bounced back, I think, in early January to sort of that 2.5% number. Then we ran into some winter weather in, in, you know, January and February, back half of January and February. I think that 2.5% is sort of, we've been operating at that level already for a while now, absent, you know, these sort of exogenous weather pressures. I think that 2.5%-3% is an eminently achievable, you know, target. You know, to your second, to your question also about, you know, sort of what's preventing us from getting to that number, which again, sort of on the surface seems pretty modest in an environment where most people seem to characterize behavioral volumes as, as robust, and, and fairly, you know, you know, high demand.
I think the other piece, and we talked about this a little bit on our earnings call, is I think a lot of behavioral demand has shifted from, or a chunk of it has shifted from the inpatient setting to the outpatient. While I think we've always been very good at what we sort of call step-down, outpatient care, which is patients being discharged from our facility who need further care, not no longer inpatient care, but outpatient care, we, I think, have, you know, really good control and relationships with those patients and have enjoyed, you know, the benefits of their outpatient care. What we haven't done as well, and I think what the industry has probably, you know, done a little bit better than us, is what we call that sort of step-in care.
These are patients who are receiving freestanding outpatient care as their sort of entree into the behavioral system. Those folks tend not to want to have that care on the campus of a behavioral hospital. I think they worry about sort of getting sucked up into that inpatient vortex, if you will. You know, I think we're embarking on a much bigger presence in that freestanding outpatient care. I think as we, as we establish more of a presence, as, you know, those demand patterns continue to increase, I think you'll see our adjusted patient day growth grow because I think what you've seen over the last several years is, our actual patient days are growing faster than our adjusted patient days, meaning that our inpatient volumes are growing faster than outpatient.
I think honestly, from an industry perspective, there's more growth occurring on the outpatient side. We just need to make sure that we participate in that to the fullest extent that we can. I think we have the ability, the investment capacity, the know-how of the business, the referral sources, etc., to prosper in that segment.
Maybe on that point, yeah, what is the appetite to add there and where are the expansion priorities? Is there any interest to expand into, say, the methadone business?
Yeah. First of all, on the outpatient side, you know, it's, as you might imagine, it's a relatively low cost, low capital investment. You know, I think you can build a perfectly appropriate, freestanding outpatient facility for an average of $1 million or so. You know, it's not a big capital commitment, and so, you know, we certainly have, you know, resources to do that. As far as the methadone business goes or the sort of medically assisted treatment business goes, I think we have historically, you know, not really warmed to that business in the sense that it didn't seem to fit in our broader continuum. You know, the methadone clinic business is really a dispensing business. It's not necessarily a treatment business.
I'm not a clinician, so I don't have a strong feeling about this, but I think if you talk to people who are, you know, addictionologists, professional addictionologists, etc., they'll sort of sometimes critique that business as, you know, really substituting one addiction for another where you're not really treating the, you know, the fundamental issues that the patient has. That tends to be what we do, whether, again, that's inpatient, outpatient. We certainly have a significant addiction business or addiction treatment business. It just tends to be more of a traditional kind of 12-step program as opposed to one that relies on, you know, medically assisted treatment.
I think we're willing and open, and I think we've, you know, we've started to, you know, develop more of a presence in that medically assisted treatment business, although I think it tends to be more integrated for us into the broader continuum of care that we offer, inpatient, outpatient, more traditional, addiction, you know, treatment care. We just think that that sort of suits us better and sort of takes advantage of all the other resources that we have in our clinical arsenal.
Great. On the cost side of the business, you booked an elevated level of medical malpractice in 2024 and expect that to moderate, I think, in 2025. Can you elaborate on the trends, you know, we've seen in recent years? Why has that increased and what gives you confidence that this will moderate?
I think the feedback that we get from, you know, insurance brokers, our third-party actuaries that we use to really help us set our level of reserves and, and consequently level of expense is that, for some time now, the frequency and/or incidence of malpractice cases is not necessarily increasing, but the value of each individual case seems to be climbing. I honestly, I don't know that that's, first of all, I think it's an industry-wide issue, meaning a hospital or healthcare industry-wide issue, but I think it even goes beyond that, that if you listen, or you follow sort of, you know, things like product liability cases or other sort of tort cases, that those dynamics are true, you know, more broadly, even beyond the healthcare and hospital space.
You know, what we did, and we discussed this, you know, in our earnings call and our announcement is, we twice a year get these, you know, these actuarial, established ranges of what our malpractice reserves and expense should be. Historically, we've sort of always targeted the midpoint of those reserves. You know, given some of the more recent developments, some of the pressure on malpractice expense in the last few years, it seemed prudent to us to take a more conservative position. In 2024, we moved ourselves kind of along that continuum of the actuarial range to sort of more of the high end of the guidance.
The notion, we hope, as I think you kind of articulated in your question, is that by doing so, you know, we'll be able now to return to kind of a more normal, you know, kind of inflationary increase for malpractice expense every year. And, you know, if there's, if there's further pressure points, etc., in the industry, we should be able to absorb that now that we're at the higher end of the range.
All right. Let's move on to the acute care hospitals. This year's flu season looks like the most severe we've seen since 2017, 2018, when we saw a lot of callouts from both payers and providers. It's always a bit more nuanced for hospitals because any volume benefit may crowd out higher acuity procedures. What's been your experience with the flu so far, and has it had a meaningful impact on other procedures?
I think you've described it pretty fairly. I mean, you know, and I think if you go back, those of you who followed UHS for some time, you know, our commentary about the flu has always been fairly consistent in that I think we always say it's unlikely to have a material impact on our earnings. Busy flu season, not busy flu season doesn't really matter. I think there's a variety of reasons for that. You touched on a few. One is that flu patients tend to be relatively low acuity, relatively low profitability. They don't get a lot of procedures done, etc. They, they're basically in the hospital. They receive, you know, perhaps some, you know, medication, etc., but, you know, they're not, you know, generating significant either revenues or profits.
You also point out that, you know, the challenge sometimes is that a really busy flu season will crowd out other business. You know, our emergency rooms sort of get overwhelmed and overrun, and we don't get other patients who might otherwise come to the emergency room. The other piece of this that I think people tend to overlook is, you know, kind of what, you know, you talked about, which is, you know, in a season where sort of everybody is getting sick or everybody's getting the flu, it really means everybody's getting the flu.
That means some of our patients get, you know, and some of them are getting admitted to the hospital, but some of our patients who have elective procedures scheduled get the flu and cancel, some of our physicians who are, you know, surgeons, etc., get the flu and cancel for several days. Some of our nurses get canceled, and we have to, you know, sort of restrict our surgery schedules and things like that. There is that element of it. The other piece I would just mention, you point out that the macro data suggests that it is the busiest flu season in quite a number of years. I think we would acknowledge that, you know, we have seen an elevated flu season, particularly in the first quarter of this year.
I will tell you that in my experience, we've seen busier flu seasons. You know, I can remember flu seasons, not, you know, all that long ago where we were so overwhelmed in our emergency rooms that we would erect tents in the parking lot to the hospitals where we would try and sort of siphon off that, you know, flu business so we could sort of isolate it and continue, you know, kind of a more normal course of treatment in the emergency room. We haven't done any of that this year. My gut is, you know, we'll see and we'll certainly share whatever information we can on sort of what the elevated flu levels were and our best guess of what the impact's gonna be in the first, will be in the first quarter.
At the end of the day, I just do not see it as either material, number one, to our, certainly to our full year results, but even to our first quarter results.
Great. Understood. Despite the strong guidance for this year, acute hospital margins still look to be trailing pre-pandemic levels by a few hundred basis points. It looks like the most significant labor gains are behind us. What are the primary drivers of margin expansion from here, and what do you think is the realistic target over the next three years or so?
You know, I think what we've said, again, pretty consistently is that we have an expectation that on a consolidated basis, we should be able to get back to pre-pandemic margins in the next couple of years. I think if you look at our behavioral business, you know, I think we're largely there. In some cases, I think you could argue we're already above pre-pandemic margins. Some of that has been with the help of these DPP payments. You know, we'll see how that plays out. I think it's been a little bit more challenging on the acute side. I think the acute business has had some structural headwinds that have been difficult to overcome to get to those pre-pandemic margins.
Probably the two most significant in my mind are the increase in professional fees or professional expenses, particularly among the anesthesiology and emergency room physicians that, you know, we engage with. It's been, you know, widely reported on an industry-wide basis that the expense of providing those services, you know, really accelerated by 150 basis points or so in late 2022 into 2023, etc. It's gonna be very difficult to recoup that, in, in any sort of permanent way. The other issue that I think you see on the acute side that you don't see as much on the behavioral side is this continued migration or transition of inpatient services to outpatient settings, you know, the, you know, continued growth in ambulatory surgery centers and freestanding imaging centers, etc.
That, you know, continues to put some pressure on acute care margins that I think is, you know, difficult to recover. I think our consolidated margins likely to get back to pre-pandemic margins. I think what that means is we're likely to get sort of above pre-pandemic margins on the behavioral side and maybe fall a little bit short on the acute side.
Do the new hospitals that you've opened up, does that help from a payer mix and margin perspective? Like, are you able to invest or start those hospitals with the, you know, right acuity and service lines such that those margins might reflect, higher acute care hospital margins overall?
Yeah. I mean, just to be very specific, the two hospitals that we're opening, one is open already in Las Vegas. We've always had a history of relatively rapid ramp-ups of new hospitals in Las Vegas, we're the largest by far market share provider in Las Vegas. You know, this just continues to fill out our network of providers, both hospitals, you know, physicians, etc. You know, we're expecting a pretty rapid ramp-up of that Vegas hospital. It just sort of, again, strengthens what's already a very strong franchise for us. The other new hospital that will open in a month or so is in Washington, D.C., where we have one existing hospital. Again, it does, I think it strengthens the market, it strengthens our position with payers, it allows us to consolidate some overhead expenses.
And in this case as well, the District is where a hospital in the District is closing, you know, essentially coincident with our opening. So it's not like we're ramping up from zero. We expect, you know, a cohort of patients to, you know, literally when we open on day one as this other hospital closes.
Great. With that, we're out of time. Steve, thank you so much for joining us here today, and please enjoy the rest of the conference.
Thanks for having me.