All right. Hi, everyone. I'm Steve Baxter, the healthcare services analyst here at Wells Fargo. We're very pleased to have Universal Health Services, a leading provider of acute and behavioral services. From the company, we have Steve Filton, CFO. Thank you very much for being here.
Thank you. Good morning.
So we will start on the acute side of the business. The first half, you know, you had historically strong volumes. You know, obviously, we're in a period where we're recovering from, you know, various COVID spikes that we saw in the first half of 2022. When you think about where we are from a volume recovery standpoint, you know, what's the story on the acute side of the business? When do we think about returning this something closer to pre-pandemic levels of growth?
So, yeah, you know, as you described it, Steve, this has been a year of pretty robust acute care volumes. There's been speculation, and I think rightfully so, that, you know, some of that recovery has been the catch-up on postponed or deferred demand that had occurred, over time during the pandemic. Everybody, even the providers themselves and investors, et cetera, would like to be able to parse it precisely to understand, you know, how much of demand is what I'll sort of call true recurring demand, and how much is sort of this recovery of some deferred procedures. It's very difficult to do. I would say, well, nigh impossible, and I don't know that anybody can really do it, with any great level of precision.
You know, we had 10% in the first quarter, 10% year-over-year, same-store adjusted admission growth. And so I think we just conclude from what is a historically sort of unprecedentedly high number, that there's got to be some level of catch-up. And what we expected and saw was a little bit of moderation in Q2. We'll probably see, I think, a little bit more moderation in Q3 and Q4, but I still think, you know, acute care volumes remain strong.
Again, the character of it that we've seen so far this year and seems to be persisting is pretty strong volumes, although somewhat lower acuity, which, at least in my mind, seems logical in the sense that I think the procedures that tended to be deferred and postponed during the pandemic were the less acute, less emergent procedures, and now they're being caught up. So I think the trends have largely continued into the back half of the year, although again, with some modest moderation and some of that extraordinary volume growth.
Got it. So when you're talking about moderation, you're talking about the year-over-year growth rate, or you're talking about moderation of what you would typically expect a Q3 to look like versus a Q2 in a more normal year?
Yeah, more, more of the year-over-year. Again, if I'm remembering correctly, I think, you know, the adjusted admission growth in Q1 was, like, 10% year-over-year. I think it was 8% in Q2. We expected it would moderate a little bit more in the back half of the year, and I think we're seeing that.
Okay, and then, you know, the acuity was going to be my next question. Can you talk a little about what you've seen on that front? I mean, it does make sense to your point, that deferrable procedures would be less acute in nature. Obviously, we've had the ongoing shift to outpatient care accelerate dramatically for certain procedure categories. What are you seeing in terms of acuity, and I guess, how has that evolved through the year?
Yeah, so look, I think you described it correctly. I mean, there are a couple of different dynamics I think occurring at the same time. One, I think, is, again, as we catch up on these procedures, the procedures that tend to be have been deferred and postponed are the less acute ones. And so we're sort of skewing during the last couple of quarters to a slightly lower acuity level that I think at some point is going to stabilize. We've also had, as you described, this dramatically accelerated shift because I think we've been seeing this shift from in to outpatient for, you know, quite frankly, decades. But it really accelerated during the pandemic. I think it really accelerated specifically and particularly amongst orthopedic procedures. It feels like we're largely through that.
You know, again, I think what you know most of the data suggests as an example is, maybe five years ago, 80% of total joint replacements, hips and knees, were being done on an inpatient basis, and now, three or five years later, it's flipped completely, and 80% are being done on an outpatient basis. But I think the reality is that means that there's not a whole lot more to go, that the procedures that are being done on an inpatient basis currently are on the older, more medically compromised population, and probably not a lot more change or not a lot more shift is likely to happen. So I think we're likely to return to, you know, what I think it was sort of that pre-pandemic, more incremental and evolutionary continuing shift of inpatient to outpatient.
Okay. Then as we think about the rate environment, you know, 2023 obviously is a done deal, I believe, from a revenue perspective at this point. You got 7.1 rate updates, and Medicaid, I think, was kind of the last outstanding piece there. I guess, give us more of a sense as you think about 2024 contracting, where things stand for commercial at this point, and what your expectation is for, for what happens to Medicaid rates. You know, they've been stronger over the past couple of years, mostly in behavioral, but I believe also in acute.
Yeah, so I think contracting rates are generally have been a positive, albeit with a bit of a lag for the providers. As you know, we've settled into a more inflationary environment than we've been experiencing for a number of years, as we're renegotiating our contracts, you know, we're beginning to get that inflationary relief in our contracts, and I think we'll continue to do that. You know, I think that process probably started, you know, mid-2022, and I think will likely continue for the foreseeable future as long as, you know, we're in a somewhat higher inflationary period. So again, I think contractual rates are generally a tailwind for us.
I think, you know, the concern that providers have and always have is sort of in an environment where medical loss ratios are going up for the payers. They have a number of levers that they can sort of pull to try and control medical loss ratio. Contractual arrangements are one, although I don't think we're really seeing that. You know, more likely, I think, and you know, probably more nuanced and a little less obvious are you know, utilization review practices and denials and you know, observation versus inpatient sorts of categorization. So, you know, we're paying a lot of close attention to that and trying to make sure that, you know, some of this sort of downshift in acuity is not driven by those kinds of things.
Not evident to us at the moment that it is, but certainly something we're, we try and be very, you know, sort of attuned to.
Even if it's not driving the acuity, do you feel like you've seen a significant change in the level of utilization management?
Well, I think for sure, from the perspective of, I think, in the very beginning of the pandemic, especially when utilization rates dropped so dramatically, so quickly, the payers, I think, were really very conscious about not being sort of overly aggressive about utilization review, et cetera, when already utilization was already so low. And I think then, as utilization patterns have returned back to kind of more normal levels, I think their sort of utilization practices and their level of aggressiveness has sort of also moderated back or regressed back to kind of, I'll call it, more normative levels.
Okay. It does seem like these Medicaid supplemental payment programs have become a bigger swing factor for your business year to year. I know that we're watching Nevada closely to see kind of what happens there. Would love to hear if there's any update on Nevada. I think there's also been some attention on whether Texas is also potentially increasing the size of some of their supplemental programs. Can you give us an update on both of those?
Yeah, I mean, first, I would just make the general comment that I think these Medicaid supplemental programs, to your point, are becoming more prevalent, and I think there's a reason for that. I mean, I think that the states are, you know, view these programs as a way to enhance Medicaid reimbursement, particularly for, you know, what I would sort of describe as safety net hospitals. That is, those hospitals that are providing inordinate levels of either, you know, Medicaid care to Medicaid patients or care to indigent patients or both. And so you see more of it. It's not, it's not an accident that you're seeing more and more of these supplemental programs, which are doing just that. They're supplementing what I think providers would describe as otherwise relatively inadequate, you know, base Medicaid rates.
In terms of the specifics that you asked about, so Texas, to your point, has increased the size to some degree of their supplemental pool. It's Texas is a pretty complicated state from a supplemental reimbursement perspective. They've got a bunch of different programs, and they tend to all interact with each other, so when one goes up, one goes down or could go down, et cetera. I think ultimately, you know, we believe that the net impact on our hospitals in Texas will be positive and it'll be a bit of a tailwind. But I think it's worth noting that, you know, when you read about, you know, an increase in the uncompensated pool, it could result in a lower amount of disproportionate share or whatever. So, you just have to keep that in mind.
It's a pretty nuanced situation. The Nevada programs, as we've been disclosing, are, you know, new, incrementally new. They are, you know, continue to be developed. We've been disclosing that, you know, one of the requirements has been that the state has said they needed to get the approval of two-thirds of the hospitals in the state to move forward. We've been advised that they've obtained that approval, and so now we think that, basically what has to happen is the state needs to file the paperwork for these programs with CMS.
They require CMS approval, but as best as we can understand it and understand the dynamics of the program, that approval should be gained at some point, and the program should be effective sometime in 2024, largely, you know, with a significant, you know, potential benefit to our hospitals in Nevada.
Okay.
And then there's some smaller programs that we've disclosed in South Carolina and Oklahoma. Again, I think mostly, these will be tailwinds in 2024.
Okay, and I know that the Nevada one, at least in terms of your current guidance, is a headwind. When you think about it being better in 2024, does that mean it's getting back to what it was, or do you think that the program size, like we've seen elsewhere, is potentially increasing too?
Yeah, so I think the crux of your question, we've been disclosing the fact that Nevada has been developing the implementation of two programs. A smaller program that we actually thought would be implemented and effective in 2023. We had about $25 million of income in our guidance or EBITDA in our guidance associated with that program. That program has been delayed in its implementation. It's also been, I think, somewhat downsized. So now we think we're gonna get about $3 million just in the fourth quarter, so that's about a $22 million headwind for us in our 2023 guidance. Now, you know, we actually raised our guidance or at least chopped off the lower end of our guidance after last quarter.
So, you know, we think we're gonna overcome that headwind, and still believe we will. But the bigger program, which is probably, you know, could be four, five, six times that, the size of the smaller program, we always imagined would be implemented in 2024, and, that's, that's still our expectation.
Okay. On the acute side, obviously, labor has been a huge amount of focus. Generally, it feels like, you know, wage inflation has been improving as we've moved through the year. What's the latest on the wage front? And, you know, what's the interaction with the strong volume growth you've seen in your ability to continue to improve wages at the pace you expect?
Yeah, I mean, so, as everybody knows, I mean, one of the big challenges for the acute care providers in 2023 was dramatic increases in the amount of premium pay. We describe it generally in the context of premium pay, which includes overtime and shift differential to our own employees, as well as payments to third-party temporary and traveling nurses. Premium pay for us, and I think for most of the industry, peaked in the first quarter of 2022, which was the last COVID surge of consequence that, you know, we experienced. Subsequent to that, as COVID volumes declined, we cut our premium pay pretty quickly. I think by the third quarter of last year, had cut premium pay, you know, almost in half.
And since that time, since the third quarter of last year, it's remained relatively stable. I think we'll make maybe a little bit more incremental, modest improvement in the third quarter this year. But to your point, I think one of the reasons why premium pay hasn't declined more than we expected that it would have declined more is the strong acute care volumes that you had asked about before. So I think we'll make a little bit of incremental progress in Q3, and then it'll be interesting to see you know, whether as we get into the busier fall and winter season you know, whether you know, we can continue to make further progress.
Certainly, it doesn't appear as if we're going to be able to get back to kind of the pre-pandemic levels of premium pay, but I also don't feel like we're at risk of getting back to those sort of extraordinary levels of premium pay that we were experiencing in the first quarter of 2022.
Okay, so when you think about the improvement that you might see in the back half of the year, is it more rate than, if you think that the volumes are going to remain, you know, fairly strong, or how are you thinking about that?
Yeah, I always feel like, you know, rate-- when it comes to that premium pay, that rate and volume sort of go hand in hand, not necessarily always in the exact same period, but, you know, the reason that rates have gone up is because the demand for hours has gone up. As the demand for hours has declined, you know, rates have declined. And I think over time, you know, sort of proportionately. So you know, again, I think what you're seeing is the demand for hours clearly a lot lower than it was, again, you know, a year or 15 months ago, and rates also, you know, quite a bit lower.
Although, again, you know, in both cases, neither, you know, the demand for hours or the rates are back to pre-pandemic levels, and it doesn't feel like they're going to get back there, you know, anytime soon.
Yeah. Okay. And then obviously, the physician subsidy expenses were a big area of focus as we came out of the second quarter, and those have, you know, escalated to a bigger headwind than you would initially plan for. So you've also stepped over that with the guidance improvement that you made. As we think about these expenses having ratcheted up so much and the pressure that these underlying business models are seeing, how do you think this plays out over the next couple of years? Like, what are the key couple opportunities you'd have to potentially manage this more efficiently as we step into 2024 and 2025?
Yeah, I mean, I think what you've seen and what we've seen and experienced as an industry is almost sort of a, and your question sort of alludes to this, kind of almost a complete reset of the business model of these physician subsidy businesses. Primarily for us, emergency room physician coverage and anesthesia coverage. You know, and I think what the industry and everybody has come to realize, I think, over the last 12 or 18 months, is that these businesses were much more heavily reliant on the profitability and the billing and the profits embedded in that billing that came from their out-of-network patients, although a relatively small percentage of their patients, but I think a relatively, you know, large amount of their earnings.
The No Surprises Act obviously had a significant impact on that, changed the profitability of these businesses. So as a consequence, whoever is running these businesses, whether they are, continue to be third-party providers, whether hospital providers themselves, you know, take on more of these, these physicians themselves and hire them and run these businesses ourselves. Whoever is running these businesses is going to find them less profitable, and as a consequence, the subsidies that we're having to pay for these businesses has increased significantly. And that's, I think, what you've seen for the first six months in our financial statements, and you know, I think they'll, you'll see a similar impact over the balance of the year.
But I feel like once we get to 2024, that basically business model has been reset at this higher level of expense, and there won't be, you know, another incremental sort of, you know, increase in expense next year, and perhaps even some level of decline or moderation as we are able to drive some, you know, greater efficiencies, whether that's through, you know, kind of more efficient staffing levels, that is, using more, let's say, CRNAs versus, you know, anesthesiologists in that area, or just, you know, getting over this sort of temporary funding requirements that we've had this year, et cetera. But, you know, again, it, there's not going to be a complete reset.
We're not going to get back to physician subsidy expense at pre-pandemic levels by any means, but I would think at a minimum, we should see those expenses level off in 2024 and maybe in sort of the better case, you know, see a bit of a moderation in those expenses.
I guess, how do you think about the financial trade-offs of potentially insourcing some of the services, especially on the ER side? Is that something you think you could do that, you know, when you think about getting rid of physician subsidy expenses, could be like a break-even proposition for you? And then operationally, what are some of the benefits of bringing those services back in-house for yourself?
Yeah, I mean, again, you know, I think the way this business changed, you know, when I started in this business a long time ago, you know, most emergency room physician coverage, anesthesia coverage was outsourced, tended to be outsourced to smaller local groups. A lot of times in a smaller community, like McAllen, Texas, you'd literally have a single ER group that was servicing, you know, the three or four hospitals in the community. But what, you know, the well-known sort of consolidators in this business, the Envision and TeamHealth in the world did was, you know, essentially, you know, roll up and consolidate all these sort of smaller, you know, franchises around the country, and there were, you know, economies of scale that they were able to generate, et cetera.
I think that worked well for both them and for the providers. I think, you know, a lot of these things tend to be cyclical, and where we're returning to or we'll return to an environment in which it's not nearly as consolidated or centralized. Hospitals will employ some more of these physicians where that makes sense, but I think we'll continue to use, you know, local and regional providers where that makes sense, et cetera. I just think that the advantages perhaps of that consolidation and sort of centralization were probably overdone and were not nearly as valuable to the industry as maybe some had thought.
Okay. And then, you know, obviously, you guys have talked about, you know, the potential over a multi-year horizon to improve margins in the acute business, you know, maybe closer to where they were pre-pandemic. Can you talk about what the key levers are? Because, you know, from an environmental perspective, it does seem like there continues to be a lot of pressure on the acute business model, wage inflation, probably not going back to where it was pre-COVID anytime soon. You mentioned some of these steps up in physician subsidy expenses. How should we think about the factors that would allow you to potentially realize some progress against that goal for the long term?
Yeah, I think that the biggest pressure on the acute business during the pandemic was that sort of crowding out factor, that as COVID volumes increased, it tended to crowd out. And I sometimes have to say, using that phrase, crowding out, because it sort of has a very physical connotation and sort of implies that, you know, COVID patients were so numerous and so ever present, that they there literally was either no room physically in the hospitals for non-COVID business, or we didn't have enough staff or whatever the issue may have been.
But the reality is, and I think we touched on it a little bit earlier, is most of that crowding out tended to be, I think, more psychological than anything else, that people were reluctant to go to hospitals, particularly for less emergent sorts of procedures. But much more so than just reluctant to go to hospitals, they were reluctant to go to physician offices, to go to have diagnostic care, you know, mammograms and colonoscopies, and that sort of thing. And, you know, whether that lasted for a year or two years, you know, depending on the individuals, et cetera, it clearly had an impact.
I think what you're seeing now, and what we sort of talked about earlier when we were talking about the kind of robust volumes, is patients are returning to these more normalized patterns across the continuum, meaning they're seeing their physicians for their annual exams, they're having the colonoscopies, they're having the mammographies. The result of those, that sort of activity, is then there's this kind of downstream issue of, you know, issues are identified, diagnoses are made, et cetera, and now there's other things being done. So that's, I think, the big opportunity for the acute business to recover. As you point out, I think that, you know, the business faces some additional challenges, you know, incremental wage pressures, et cetera.
Although, again, premium pay and the reduction in premium pay, I think, is a big recovery item. But yeah, I think and we've sort of made this point, I mean, we believe that the acute business can recover a substantial amount of, you know, the margin gap that exists today-
Yeah
... between pre-pandemic margins, but maybe not all of it. I think, you know, we're more optimistic that on the behavioral side, you know, all of those margins are recoverable over time.
Okay. I think that makes sense. And then to switch to behavioral, and then one thing we've heard, you know, over the past few quarters is that, you know, volume growth in some ways was held back by your ability to staff and hire at reasonable rates in the behavioral business. Where do we stand today? Do you feel like we've largely moved past that, or do you feel like that is still a bit of a handbrake on the growth of the business as we get into the back half of the year?
Yeah, we certainly have made a significant amount of progress, and I think we've made the point, you know, multiple times and continue to make this. I think it continues to be a relevant point, that I'm gonna say since about the spring of last year, when COVID volumes declined from the big COVID surge early last year, we've continued to have net positive new hires, and that has allowed us to, you know, generally continue to you know, grow volumes, mostly, you know, adjusted patient days for the most part. It's a bit of a sort of uneven kind of trajectory in the sense that there still is a fair amount of turnover. We're hiring a lot of people, but there is a lot of turnover.
Again, not just for us, but for the entire industry. Turnover has been a challenge for the hospital industry, you know, I'm gonna say indefinitely, but it really accelerated during the pandemic. It has gotten somewhat better, but it's still challenging because it means that while we're hiring a lot of new people, a lot of them have to be trained and oriented. We're hiring more-
Mm-hmm
... and more inexperienced nurses and clinicians right out of school, et cetera, and they require more training, et cetera. So there are periods, and I think the second quarter was a decent example of this, there are periods where we've hired a lot of people, but they are unproductive for periods of time, meaning they're drawing salaries, they're getting paid, but they're not treating patients, they're not allowing us to to admit more patients, et cetera. But over time, this ability to hire more people and, and frankly, the ability to continue to drive down those turnover rates will allow us to treat more patients, et cetera.
I think that's why, as I, you know, alluded to earlier, our sense of being able to return to, you know, pre-pandemic behavioral margins and maybe even something, you know, better to peak behavioral margins, which really probably go back to 2014, 2015, is something that we envision as being achievable, you know, certainly over, you know, several more years. Now, I don't mean to imply that it's gonna happen in the next quarter or two, but should be a multi-year progression.
... Yeah, so that's gonna be the follow-up. So then when you think about the inefficiency, I guess, you saw from the hiring in the second quarter, what's your thinking on how long it's gonna take to kind of drive that out or bring it back down to closer to, to typical levels? Is that something that can happen as you exit the year? Is it a third quarter thing? I guess, how long does that take?
Yeah, I mean, again, I think our general sense is it should improve over the balance of the year. But to your point, I mean, one of the challenges in sort of projecting this with absolute precision is, you know, there's a number of moving parts, you know. So we know how many net hires we have, but, you know, how many of those people are we going to lose and what's the turnover? And again, generally, all these factors have been gradually improving, and if we go back and we look back over the last certainly 15, maybe 18 months, you know, we're gonna see steady improvement, but it's not absolutely, you know, ratable and predictable.
So, you know, again, you know, one of the things that I encourage people to do from a behavioral perspective last quarter was to look at the last six months, look at the last twelve months, and I think that gives you a better picture of the improvement in the behavioral business than sort of the second quarter performance standing on its own. And I think that's gonna be true going forward, that no one quarter, good or bad, is gonna be as relevant as sort of the longer-term performance of the business.
Okay. And then with the second quarter, you discussed that, I think, acute behavioral volumes were largely in line with your expectations. I think you're pleased there. There were some residential volume weakness, I believe, and I think you called out, like, a handful of specific facilities that you were in the process of maybe remediating whatever the underlying issue was. Where does that kind of sit as we move into the back half of the year?
Yeah, and look, I make the point, you know, people ask, not just about this question, but, you know, we made, you know, a number of comments about second quarter performance. So I always remind people that was about six weeks ago. Nothing has changed terribly dramatically. I think all the things that we pointed to, and, you know, I think we talked a little bit about this on the acute side, all the trends that we sort of talked about, I think, have generally remained in place. So making improvement on those, the handful of sort of facilities that had particularly nuanced problems, making progress on getting more of these clinicians trained and, you know, on the floors, treating patients, et cetera.
And I think we talked about that as a process that would sort of, you know, take place throughout the third and fourth quarters, for our behavioral business, and I think that's the way it's playing out.
Okay. As you think about the next couple of years, and, you know, I'm still confident that you would think there's a lot of unmet need in your markets on the behavioral side, I guess, what do you need to see to potentially start adding capacity and beds in a more aggressive way?
Yeah, I mean, so, you know, generally, adding beds is driven by the data that we accumulate on what, you know, we describe as sort of deflections. These are patients who come to us through referral sources, through internet inquiries, through, you know, calls to our 800 number, and, you know, whom we sort of go through the process of triaging and determine that they are, you know, they meet admission criteria, they're, you know, they meet financial criteria, all those sorts of things. And, but we don't have room for them, either physically, we don't have a bed for them, which for years had been sort of the predominant issue. The issue that I think has been more predominant over the last, you know, certainly two, three years of the pandemic, has been we don't have enough staff for them.
And so as a consequence, as an example, you know, during the pandemic, we stopped building new beds, or we certainly decelerated the rate of building new behavioral beds, 'cause the view was, look, if we can't staff the beds that we have, what's the point of building new beds that we can't staff? But as we continue to solve the staffing problem, and the volumes continue to demonstrate that they're there, and that, you know, literally is a facility-by-facility, market-by-market sort of determination, I think that, you know, we'll return to a model in which, you know, we're pretty routinely adding 6, you know, 8, you know, 100, 1,000 new beds a year, where the demand is justified because, you know, we'll be able to staff those beds.
Again, you know, I think we've made this point throughout the pandemic, that we didn't think that there was anything about the underlying behavioral demand that had diminished. As a matter of fact, I think there's a lot of evidence that suggests that the pandemic, in many ways, tended to exacerbate and accelerate the need for behavioral care.
Has the company changed its thinking at all on, on whether addiction treatment services could, over time, be a bigger part of the behavioral business? I guess, what do you think about the fundamental attractiveness of the addiction business?
So, you know, the point that I always make about this topic is, you know, we've been treating patients with addiction issues for years and years and years. We've tended to do that in kind of a more traditional therapeutic way, you know, what used to be sort of a standard 28-day program, and now has, you know, many different forms. But the business that we haven't necessarily gotten into in a big way that our public peer has is medically assisted treatment, methadone clinics, that sort of thing.
I think it makes sense, you know, for a company like us that has such a broad continuum of care, meaning, you know, across a continuum of in- and outpatient care, sort of pre-inpatient, post, you know, inpatient, across many, many diagnoses, you know, whether that's, you know, general psychiatric diagnoses, depression, autism, eating disorders, trauma, PTSD, all those sorts of things, that, that having sort of that arrow in the quiver of medically assisted treatment makes more sense.
So, you know, I think we'll continue to develop more of a presence in that business, but I think it will be integrated into, you know, and more synthesized into our full continuum of care, which I think we think is going to be most attractive to employers and to insurers and to the government to sort of say, look, we, you know, addiction treatment is clearly an issue, and obviously, opioid treatment is, you know, kind of the thing that gets the headlines these days. But, you know, alcohol abuse and other drugs remain a huge problem in the addiction area. So, you know, again, I just want to make the point that we've always had a significant presence in addiction treatment.
We'll probably expand our capacity in medically assisted treatment, at least incrementally, but continue to build out our ability to treat people with addiction illness, because unfortunately, socially, that just seems like it's not going away as a problem, as a societal issue.
Got it. And then on the rate side of things for behavioral, you know, obviously there's a supply-demand imbalance there that the company's been able to use to help drive up, you know, rate a little bit, get paid a little bit more appropriately on the Medicaid side of the business in particular. I guess, how do you think about the sustainability of larger Medicaid rate increases as we move into 2024 and beyond?
Yeah, and again, I think you described it correctly, Steve, in the sense that I think our ability to leverage higher rates during the pandemic especially has been in an environment where behavioral providers, us obviously, but I think, you know, mostly across the industry, have been somewhat capacity constrained, and they've been unable to treat all the patients being presented to us. You know, it leaves us in a position of being able to ask our payers to pay us rates that we believe are competitive and are fair, and allow us to provide the appropriate treatment to their members.
And I think, you know, we've done that successfully, you know, over the last couple of years, and it's reflected in the higher, you know, revenue per adjusted day growth that we've been experiencing over the last several years. I think what we said, you know, going into the year, if you look at it, our revenue per adjusted day, pre-pandemic was growing pretty regularly and consistently, maybe 2 or 3% a year. During the pandemic, it was probably closer to 5 or 6%. You know, we said that over the next few years, that number probably moderates to maybe 4 or 5% growth. We've been running certainly on the high end of that, like 5%.
It feels like that just should be sustainable for certainly at least the intermediate term.
And then, maybe the last question, Medicaid redetermination is obviously a big area of focus in both your businesses. I guess, what are you seeing at this point on the acute and behavioral side that you can talk about?
Yeah, I mean, it's an interesting thing. I mean, as you suggest, I mean, it's certainly gotten a lot of sort of headline coverage, and we know that there have been significant numbers of people redetermined off the Medicaid rolls as is being reported. We're just not seeing a significant impact in our hospitals now, and I think that's true in both acute and behavioral. And I think there's a couple of reasons for that. I mean, one is obviously while people may be getting redetermined off, we, as providers, are not going to feel that impact until they actually present themselves in a hospital emergency room or, you know, a behavioral facility, et cetera. So there is sort of a time lag, I think, associated with that.
I think the other sort of feedback that we've been getting from our hospitals is that it feels like a lot of these people are being redetermined off for administrative reasons, and are getting re-enrolled pretty quickly and efficiently. So again, the impact doesn't seem to be so great. So, you know, I think we've actually probably been a little bit more cautious in our outlook than some of our peers about the potential for some impact from Medicaid redeterminations over the balance of the year. But, you know, at least so far, we'd have to say that it doesn't seem to be having much of a measurable impact.
Okay, and you don't feel like it's really showing up in terms of, you know, higher commercial, like you're not seeing transition exchange coverage or any major changes?
Yeah, no, no significant changes in payer mix, either positive or negative, I think that we would attribute to Medicaid redeterminations.
Okay. Well, perfect. I think it's a good place to leave it. So thanks so much for your time.
Okay. Thanks, everybody.