Earnings Call: Q1 2021

Apr 27, 2021

Good day and thank you for standing by. Welcome to the First Quarter 2021 Earnings Conference Call. At this time, all participants are in a listen only mode. After the speakers' presentation, there will be a question and answer session. I would now like to hand the conference over to your speaker today, Steve Filton, Chief Financial Officer. Please go ahead. Good morning. Mark Miller is also joining us this morning. We welcome you to this review of Universal Health Service' Results for the Q1 ended March 31, 2021. During the conference call, we'll be using words such as believes, expects, For anyone not familiar with the risks and uncertainties inherent in these forward looking statements, I recommend a careful reading of the section on risk factors And forward looking statements and risk factors in our Form 10 ks for the year ended December 31, 2020. We'd like to highlight just a couple of developments and business trends before opening the call up to questions. As discussed in our press release last night, the company reported net income attributable to UHS per diluted share of $2.43 for the Q1 of 2021. After adjusting for the impact of the items reflected on the supplemental schedule as included With the press release, our adjusted net income attributable to UHS per diluted share was $2.44 for the quarter ended March 31, 20 During the Q1 of 2021, we received approximately $188,000,000 of additional CARES Act grant funds. While we continue to experience residual effects from the COVID-nineteen virus, the net impact on lost revenues and incremental expenses in 2021 has not been nearly as severe as it was in 2020 and consequently we have begun the process of returning These $188,000,000 in CARES Act funds to the federal government and expect that process to be completed shortly. As previously disclosed, we also returned $695,000,000 of Medicare accelerated payments to the federal government in the Q1 of 2021. As I noted during the Q1 of 2021, we continued to experience certain unfavorable Impacts on our operations and financial results from the COVID-nineteen pandemic. Specifically, we experienced an increased Wave of COVID patients in December 2020, which peaked in the first half of January twenty twenty one. The negative impact resulting from this elevated level of COVID volumes was primarily a function of accompanying declines in elective and scheduled procedures And both acute and behavioral patient days, along with increased expense pressures, particularly on salaries Our cash generated from operating activities was $72,000,000 during the first The decline in cash provided by operating activities was driven by the aforementioned repayment of $695,000,000 of Medicare accelerated payments. We spent $247,000,000 on capital expenditures during the Q1 of 2021. Our accounts receivable days outstanding decreased to 50 days during the Q1 of 2021 as compared to 55 days In the Q4 of 2020, as we recovered from the billing and collection delays we experienced in the 4th quarter as a result of our previously disclosed information technology incident. At December 31, 2021, our ratio of debt to Total capitalization declined to 35.7% as compared to 41.3% at March 31, 2020. In light of our expectation that COVID volumes are likely to continue a downward trajectory in 2021 as more vaccines become available and the Compounding pressures on our operations and financial results ease. Our Board of Directors approved the resumption of our regular quarterly dividend with the first Quarterly payment of $0.20 per share made on March 31st. The Board also approved the resumption of our share repurchase program We are pleased with our Q1 2021 operating results, which were just slightly ahead of our internal forecast. The pace of the recovery from the pandemic is still difficult to predict with precision, but we assume the COVID impact will generally ease at an increase in cadence throughout 2021, and we remain comfortable that we will achieve our full year 2021 earnings guidance. We are pleased to answer your questions at this time. Your first question is from Justin Lake with Wolfe Research. Your line is open. Hi. Yes, thanks. This is Perry Wong dialing in for Justin. My question is around pricing. It looks like your pricing was up about 26%, which is notably higher than your peers. I was wondering if you could give any color on what's driving that increase. Was it Mostly due to higher acuity from COVID cases or is there any benefit from better commercial mix there? Thanks. Sure. Well, obviously, we've seen during the entire pandemic, our pricing is above Well above historical levels and the main driver of that has been the higher acuity of our COVID patients And to a lesser degree on non COVID patients as well as, so I think some deferred care, etcetera, is driving higher pricing. I think our pricing, particularly our acute care pricing in quarter 1 was particularly high for a number of reasons. In the Q4, we talked about the fact that as a result of our IT event, our billing and collection And some lower net revenue based on our regular accounting conventions. We anticipated that we would recover some of that As we caught up on our billing and collection, and I think that did in fact occur in Q1, and I think we probably benefited to The tune of maybe $10,000,000 or $15,000,000 in that regard. I think that we also benefited from the presence of HRSA reimbursement, this is the government's the federal government's reimbursement of non insured or uninsured Patients with the COVID diagnosis, I think, which really there was very little of that in Q1 of last year and that's Another probably $15,000,000 or $20,000,000 And then there's a small amount of state and local supplemental payments That we received in Q1, mostly related to the treatment of COVID patients, maybe $5,000,000 to $10,000,000 So I think those items are The sort of non recurring, I should say non recurring, but items that we had in Q1 that we didn't have in Q1 of last year. Great. Thanks. Your next question is from Kevin Schback with Bank of America. Your line is open. Great, thanks. I guess maybe start off by asking how Q1 Shaped up versus your internal expectations. So I guess it was a bit above the Street, but it sounds like you're only reaffirming guidance even though you continue to expect things Sure. So Kevin, I did actually say in my prepared remarks that the Q1 results were just slightly ahead of our internal forecast, Which is partly why we've chosen not to make any changes to guidance. We feel like we're largely on track. The things that we're watching So to the obvious things, we assume that as the year progresses, and this is what our guidance assumed as well, that COVID volumes will continue to decline, non COVID volumes in both business segments will continue to recover And also, I think quite importantly, labor pressures will ease, and those pressures will be manifest And lower wage rate increases as well as the ability to treat more patients, particularly on the behavioral side. And then I guess just a follow-up there. As we think about that volume returning back to normal, I guess it's one of the Things that we're hearing conflicting information from, it seems like the hospital companies generally expect labor pressure to ease, but I guess some of the staffing companies continue to expect Labor shortfalls, etcetera, as volumes return putting upward pressure on demand there and we see Nurses potentially look to leave the workforce. I guess, how are you thinking about margins on that volume as it returns back to normal? We normally think about lower acuity volume to be coming in at lower margins and then that put and take on the labor side. Yes. Look, I think, Kevin, that the notion is that the things that have driven the pressure on Both our wage rates and just on the overall availability of mostly clinical, but in some cases non clinical personnel Now are things like the actual virus itself. During the last 12, 13 months, at any point in time, we've had employees who are sidelined Either with the virus itself or because they're being quarantined because of exposure to the virus, we've got employees who have Suffered burnout and there's been a lot written about that. We've got employees who are quite frankly chasing premium dollars elsewhere Where hospitals are paying really sort of extraordinary amounts because of the pressures of the pandemic, etcetera. I think our point of view is that again, As more of our employees get vaccinated, we'll have fewer and fewer of them out. As more and more of the The population gets vaccinated, we'll have fewer and fewer COVID patients. There'll be less burnout. There'll be a willingness of nurses, especially nurses To return to the workplace, they won't have the opportunity to chase those premium dollars elsewhere, etcetera. To your sort of The crux of your point, whether we return to the same sort of supply and demand balance of labor that we had pre pandemic, hard to say. But certainly, I think we have a view that the labor pressures that we've experienced over the last 13 or 14 months Should certainly ease measurably as we continue to recover from the virus. Your next question is from Ralph Giacobbe with Citi. Your line is open. Great. Thanks. Good morning. Steve, any weather impact to call out in the quarter? And maybe if you could just give A sense of how you exited March and if you're willing to just discuss sort of early trends you've seen so far in April? Yes. So I talked about the COVID trends in my prepared remarks, Ralph, saying that In almost all of our hospitals, volume of COVID patients peaked in the first half of January And continue to level off as the quarter went on. And then I would say kind of late February, early March, we started to see measurable recovery, particularly in The Q Business, in elective and scheduled procedural volumes. I think the good news about the weather is while it certainly had an impact in a broad geographic swath of our markets that included Texas and Oklahoma and Arkansas and Tennessee, because it occurred largely, I think in the middle of the quarter, and because I think it So widespread, it's not like we were really losing market share to competitors during that time. I think people were just staying home or stuck at home. And I think Because they had 4 or 6 weeks to recoup whatever procedures they had missed, I think by the end of the quarter, the impact was not really significant. So at the end of the day for I think both the reason of the COVID Decline in COVID volumes and the recovery from the weather events, clearly March was We exited the quarter in March a lot more profitably than we began the quarter in January. Okay. I think those trends are helpful. I'm sorry. And I would say those trends have continued into April as well. Okay. Got it. That's helpful. And then Just on the guidance, obviously, you're reaffirming, you've talked about sort of the cadence of earnings improving sort of as you move through the year, generally sort of Sounds like in line with kind of your initial expectations. But what about sequestration? Can you size the benefit of that? And why doesn't that flow Through the number or their offsets, any help there? Sure. It's a good question and I think it was asked on the Q4 call as well. And I think what we said at Time wise, we really didn't make a specific assumption about sequestration in our budget forecast. Because this year was so difficult to forecast in terms of volumes and acuity And how they would both kind of trend as the year went on, etcetera. We were much more focused sort of on those issues than we were on sort of these specific reimbursement issues. So we have said that having the sequestration waiver extended is a benefit To us, a $10,000,000 or $11,000,000 a quarter, but I wouldn't describe it as a pickup of $10,000,000 or $11,000,000 per se in our Guidance, I would describe it more sort of accurately as a bit of a cushion in our guidance because we didn't really make a specific assumption about it. Okay. All right. Fair enough. Thank you. Your next question is from Josh Raskin with Nephron. Your line is open. Hi, good morning. This is Marco on for Josh. Thanks for taking the question. I just had a quick one. It seems like UHS is seeing a larger Spread between admissions and adjusted admissions than some of its peers. So is there any reason why you aren't seeing those outpatient volumes coming back Quicker, and did the weather events of the Q1 impact outpatient volumes differently than on the inpatient side? Thanks. Yes. So I think and we've talked about this in previous calls. I think the dynamic, the single dynamic that probably most separates our experience from our public acute care hospital peers is the percentage proportionally of COVID patients that we've treated, we've talked in the last few quarters about the fact that something like The low to mid teens percentage of our admissions on the acute side have been COVID diagnosed patients. And I think our peers are either in the high single digits or maybe 8%, 9%, 10%. So that's a pretty significant difference. That affects a lot of things. I think it affects our cost structure. It affects our length of stay. And to your point, I think it also affects Outpatient procedures and scheduled, particularly scheduled and elective procedures and it affects emergency room volume as well, Obviously, a lot of that is outpatient ultimately. So I think that's probably the single biggest reason why our outpatient hasn't Recovered as much. And then your question about the weather is correct. I mean, I think weather events tend to affect outpatient More than inpatient because obviously if you have an urgent procedure, if you're having a heart attack or stroke, you're still going to find your way to the emergency room as opposed to if you're having hip surgery or knee surgery, whatever it may be. But again, I'm going to make the point that I think in the end, we recovered most of those deferred outpatient Your next question is from Jamie Kearse with Goldman Sachs. Your line is open. Hey, good morning. Just first question on the quarter. I wanted to talk about COVID patients for a second. I know the question was asked a few times last year and Basically, the response was that COVID patients aren't very profitable. I'm wondering if that's changed at all because you've Had all these learnings over the last year, it's maybe a healthier patient population, lower length of stay, things like that. So Can you comment on the impact of your COVID census in the quarter on revenue per adjusted admission and also the EBITDA impact? Yes. So the point that we've made historically, and I would repeat because I think it's still valid, is that medical patients in general are less profitable than Surgical or procedural patients, COVID patients are medical patients and therefore, I think that's equally true of them. The other issue is that COVID patients tend to be sicker. They're more acutely ill. They clearly have a longer length of stay than our regular medical patients. And that means that the costs associated with them are higher. To your point about, I think, kind of developing treatments and protocols, I do think that clinically, We and I think all hospitals have gotten more adept and more efficient at treating COVID patients over the last 12, 13, 14 months as you might expect. I think we learned a lot about what the right things and the wrong things are to do. But unfortunately, a lot of those More efficient and better clinical treatments are also very expensive. So things like Severe, one of the main drugs that are being used to treat COVID patients are very expensive. And so again, this dynamic of the profitability COVID patients versus non COVID patients, I think, still exist, that is COVID patients are simply less profitable Then the surgical and procedural patients that they have generally crowded out during the pandemic. Okay. That's helpful. And then just one on surgical volumes. I know you don't report those, but maybe you could comment on what you Saw across the months of the quarter, both on the inpatient and outpatient surgical side and any categories or sites of care that are recovering faster Or slower than others. Yes. And again, I mean, I think what we have found and we have found this again throughout the entire pandemic Scheduled procedures at non COVID business tends to decline, and I think we certainly experienced that in Q1. So In the January timeframe when COVID volumes were peaking, I would say that surgical And elective procedures were probably at 75% or 80% of pre pandemic levels. I think by the end of the quarter, As COVID volumes have declined pretty measurably, we were at 95% plus of pre pandemic elective and Your next question is from Frank Morgan with UHF. Your line is open. Frank Morgan here. Yes, I have a cost question. You talked about some of the markets where you see that as being worse. And I don't want to put words in your mouth, but is it fair to say that the limiting factor in behavioral healthcare is in fact Still labor, the demand is higher than what you can serve given the labor pressure. And if that is true, do you How do you balance just sacrificing margin to get that incremental revenue in that higher levels of top line? Thanks. Yes. So I think, Frank, you accurately framed the question. We've talked about pressures on labor Really from the beginning of the pandemic, and I think most of our hospital company peers have done as well. I'm not sure we're all experiencing it in the same markets and to the same degree, but I think it certainly is a macro issue. Interestingly, we have said throughout that the labor shortage has manifested itself differently in our 2 business segments. I think on the acute side, We certainly have seen an increase in wage rates themselves. We've seen elevated usage of over time And shift differential and usage of temporary and traveling nurses, all of which are measurably more expensive than our base Wage rate for nurses and other clinical personnel. On the behavioral side, if you measure it by When salaries and wages per adjusted patient day, which I think is the right way of measuring, you'll see that the cost of labor isn't going up all that much. The real challenge is we just simply can't pay enough to get sufficient Personnel in at least some of our hospitals and some of our markets. And so I would say that on the behavioral side, and I think you alluded to this in your question, Shortage of appropriate clinical and in some cases non clinical personnel are probably the single biggest obstacle and head Wind to getting back to pre pandemic volumes and quite frankly even above pre pandemic volumes. And I can assure you that it's probably the I'm not saying probably actually, I would say most certainly the single biggest focus of our operators As we turn our attention to what we need to do to both recruit and retain The proper amount of nurses and that obviously includes proper pay rates. So we're constantly doing compensation surveys to make sure that we're remaining competitive. We're looking at our processes for recruiting and hiring and our processes for mentoring new nurses and new graduates. All those sort of things are a focus of ours. And we've made some progress. And I think As my earlier comments indicated, there's an expectation and then a hope that as the pandemic eases and the pressures of the pandemic ease, The labor pressures will ease as well and that some of the initiatives that we've been implementing will gain more traction. Thank you. Your next question is from Peter Chickering with Deutsche Bank. A question for Steve and Mark, if you want to jump in. If we step back a minute and look at the behavioral market, do you think that you guys are growing in line, faster or slower than overall demand? And if slower, can you give us color on why you're going slower and what should change during 2021? Mark, do you want to comment first? No, you can go ahead, Steve. Okay. So and I think my response to Frank, To some degree, it covers this. Look, and I've said this before, during the pandemic, every one of our internal Data points and metrics indicate that volume continues to or demand, I should say, continues to increase At least at sort of pre pandemic levels, if not in many cases above pre pandemic levels. So we measure that By the amount of incoming or inbound call traffic, telephone calls, Internet inquiries, etcetera. And I think there's also macro information out there that suggests that The number of diagnosable behavioral illnesses have continued to increase and there's been a lot written about the fact that mental health Stress, etcetera, has been greater during the pandemic for a variety of reasons. And again, our biggest challenge throughout has really been our ability to satisfy By that demand, and again, labor has probably been labor shortages have probably been the single biggest impediment Doing that, and that tends to be very geography specific, so that there are hospitals in which we do not have those issues and we're seeing demand growing And volumes increasing and then there are markets and geographies where we clearly see that taking place. I think it's worth noting That in the markets where we tend to experience those problems, every, again, data point that we have suggests that our peers are Experiencing those same issues in those geographies. So where we've had to cap or close beds because of the unavailability of clinical personnel, We know that and there's evidence that our peers have had to do the same thing in those same geographies. And I would just add to what Steve said, we have been dealing with certain staffing issues for a while now. We are taking new and different actions We try to combat some of this with just improvement in some of our internal processes that we think And we have confidence we'll have a different outcome for us going forward. So when these specific markets Ease up a little bit. We will be probably more ready maybe than we've been in the past to capitalize on that By improving operationally some of the things that we are doing to attract staff, keep staff and so on. Okay. And then 2 quick follow ups on the premium labor comments that you talked about. Can you help us quantify how much it impacted costs The Q1, looking at premium hours as a percent of all nursing hours, where did it peak during 1Q? Where do you guys exit in March? And as you look to 2Q, is it Fair to think about margins improving due to lower premium labor despite a reduction from the strong pricing seen in 1Q? Yes, Pito. So I would say this, at the beginning of the quarter, The way we measure sort of the impact of the labor pressures on wage rates is we measure the percentage of our Nursing hours in particular that are being paid at premium rates, things like overtime and registry and traveling nurses, etcetera. I would say in the beginning of the quarter when our COVID volumes really peaked, the percentage of our nursing hours that were being paid at Premium rates were in the low double digits, 10%, 11%, 12%, something like that. By the end of the quarter, I think those rates were maybe half of And while that doesn't necessarily a shift of 500 or 600 basis Doesn't seem huge. I think that it's worth making the point that those premium hours are often being paid at 2 or 3 times the rate of our regular hours. So the changes in the number of hours don't have to be all that significant to really start to drive As volume changes. So to your last point, I think that we think that as those pressures ease and as the percentage of Premium hours come down to more normalized historical levels, they should have a beneficial impact On our margins, because while I think our revenues will also come down because acuity will come down, I think that the Incremental rate pressure is greater than the decline in revenues than we would anticipate. Okay, great. And then my last quick question here. You talked about sort of monthly trends for acute. Can you do the same for behavioral? How do patient days track sort of in January in the peak of the COVID surge? Sort of how did it exit March and any comments on April? Thanks so much. Yes. So again, I think behavioral patient days were about 4% below last year for the quarter. I think at the beginning of the quarter, when COVID volumes were Their highest, that was probably more like 6% or 7% down and at the end of the quarter, more like 2% or 3% down. And again, the expectation, it may not be a steady progression like that, but I think our expectation is those volumes We'll continue to improve as the year progresses, both because the COVID pressures will ease And on a related note, the labor pressures will ease as well. And then one clarification on that, when you're saying exiting sort of down 2%, 3% sort of March April, Is that on 2020, which the comps got very easy for obvious reasons or that versus 2019? Thanks. Yes. So when I say pre pandemic, we generally are using 2019 as that pre pandemic measure. So that's what I'm referring to. Great. Thanks, guys. Your next question is from A. J. Rice of Credit Suisse. Your line is open. Hi, everybody. Couple of quick questions hopefully. 1, obviously, you're reinstating the share repurchase I wondered on capital deployment elsewhere, the M and A pipeline, both it sounded like there might be a few things that you were looking at last Quarter, any update on whether those still remain in play? And then also, there's been press reporting about Some larger deals that private equity has on that I would broadly describe as behavioral that might be in the market. Any Just any update on your thinking about whether there's likely to be meaningful M and A this year from your perspective? Yes, I'll answer that, A. J, it's Mark. We continue to look at deals on both sides. I would not categorize It is likely, because we're in the middle of a lot of this investigation, but there are And it seems like there is a little bit more activity happening right now on both sides. So I'm always optimistic that we're Steve, you made a lot of comments about what's happening with labor and how that's a constraint on volume growth in the behavioral side. The other two metrics that have impacted pre pandemic, the growth trends in behavioral have been sort of the pricing dynamics And also the length of stay pressures that have generally been driven by Medicare Medicaid Managed Care. Can you give us your updated thoughts? You've been doing better on pricing. I don't know whether you think pricing like you're seeing now will continue, but any thoughts About that and then also where we are with the whole length of stay issue relative to Medicaid managed care. Yes. So I mean, I think what we've said over the course of the last several quarters is that So the pre pandemic, I think our behavioral pricing was increasing on average at about a 2% to 3% rate Based on revenue per adjusted day base, during the pandemic, That increase has been more like in the 5% or 6% range. I think some of that elevated level of pricing The increase is due to a bit of an easing of pressure on the part of our managed care insurance payers. We're seeing fewer denials, less charity care during the pandemic. While we Love if that behavior continued post pandemic, I suspect that managed care may become a little bit more aggressive as the pandemic eases. On the other hand, some of that increase, I think, is more permanent in that we've gotten we've been, I think, much more focused and aggressive about Obtaining increases from particularly from some of our managed Medicaid payers from whom we have not had increases in quite some time, Etcetera. And obviously, those are more sustainable. So my gut is that once the pandemic eases some more, That behavioral pricing increase will settle in somewhere in between the sort of two numbers that I gave before, maybe in 3%, 4% range. So that'll be a little bit higher than historical, but a little bit lower than where we've been running over the last several quarters. And I think the same is generally true at length of stay. We've not seen a lot more transition to managed Medicaid during The pandemic, I don't know that it was an appropriate time for states to make big changes in their Medicaid programs. But also as I think we've disclosed before, the vast majority of our Medicaid patients, certainly something like 3 quarters of them are already in managed Medicaid Program, so I don't think we think that the impact of incremental or additional patients Migrating to managed Medicaid will be that significant in the future. And I think we made this point in late 2019 early in 2020, in January February of 2020, what I would call pre pandemic, Length of stay has been leveling off, labor shortages have been leveling off, etcetera. And then The pandemic hits in mid March of 2020 and the bottom sort of falls out. But I think we felt like we had made a lot of progress on those couple of issues prior to the pandemic really beginning to impact us. Okay. Maybe one last very specific question. And this may be too granular. Tell me if you want to just take it up offline. But If I look at that corporate expense item, it was sort of consistent this year versus last year. But I noticed last year Tended to drop off by about $20,000,000 to $25,000,000 in the second and third quarter. And it seems like that was a bigger drop than you traditionally did pre pandemic. Is there should we look for something seasonal pattern more like last year? Or Was that somehow driven by what happened with the pandemic and therefore maybe it doesn't have the Seasonal drop that we saw last year, but it's sort of more muted going forward. Yes. So honestly, A. J, it's question that you asked us yesterday and we continue to look at it, I will tell you that I think potentially Probably the biggest swing factor may be our own health benefits, which like everybody else, I mean, started pandemic at a sort of a normal level and that dropped down as people had deferred care and not nearly as much care and now are sort of increasing back up Increasing. So we will look at that I think further and try and give people a better sense of how they should model it in the future. It strikes us that that's the biggest swing factor. Okay. All right. Well, that's interesting incremental. Thanks for that. Sure. Your final question is from John Ransom with Raymond James. Your line is open. Hey, good morning. One for Steve and one for Mark. Steve, just want to just get you to confirm some math, if you would, on All of the 2021 one timers, including bad debt recovery, HRSA, Sequester and anything else that you think We should pull out as we think about our 2022 comparison. So just kind of a total kind of good guy EBITDA number would be great. And then for Mark, Yes. We know there's a big psych deal in the marketplace. They want a big price, something like 3 times revenue. It's a premium asset. When you guys look at something like that and think about running your returns, how do you put that through the filter of analysis? Thanks. Do you want me to go on that, Steve? Sure. Okay. So when we're looking at any deal, I mean, you're mentioning one particular one, but when we look at any deal, it's Fairly consistent as far as our approach goes. I mean, if we think that the possible acquisition has merit, We're obviously going to do our diligence to figure out pricing and what we're comfortable at. And there are a lot of factors that go into it, which I won't go into everything here, but certainly an asset on the behavioral side, We would consider the markets where the seller is already doing business And how that overlaps with our markets. And that will play a big part in determining how interested we are. So Same thing on the acute care side. If we see something on acute, we would actually probably be more interested if there were synergies in markets where we already Play as long as we didn't have FTC issues, because we could build up our markets a little more. It's different on the behavioral side, but that Consideration is a big one for us. And then obviously, the pricing and who else is in the market competing against us. So we continue to look at A couple of different opportunities on the BH side and when it all comes to fruition, we'll you'll certainly know about that. And then I'll just very quickly recap the sort of Extraordinary for want of a better word, particularly acute care revenue items in the quarter. I think we quantified the IT event impact that is the recovery and collection of our aged receivables from Q4 In the sort of $10,000,000 to $15,000,000 range, state and local COVID related reimbursement in the $5,000,000 to $10,000,000 range And the HRSA reimbursement of non or uninsured COVID patients in the sort of $15,000,000 to $20,000,000 range, I think those are the items we talked about before. I'm sorry, I got that. I was thinking for the full year, as we think about full year 2021. I know the bad debt recovery won't recur, I was trying to get an annual number. I got the quarter number. Okay. I'm sorry. So yes, the IT event really is a one time thing. The state and local sort of reimbursement is difficult to project and the HRSA monies at the moment You know, are sort of slated to go through the national emergency date, which I think is currently July. I think the administration has suggested they anticipated going through the end of the year, but technically, at least at the moment, it only goes through July. So We'll have to see what that benefit is. Okay. Thank you. Thank you. We have no further questions at this time. I turn the call back to presenters for closing remarks. Okay. We just like to thank everybody for their time and look forward to