Surgery Partners, Inc.

Greetings and welcome to the Surgery Partners First Quarter 2023 Earnings Call. At this time, all participants are in a listen-only mode. A brief question and answer session will follow the formal presentation. If anyone should require operator assistance during the conference, please press star zero on your telephone keypad. As a reminder, this conference is being recorded. It is now my pleasure to introduce your host, Dave Dougherty, Chief Financial Officer. Thank you, Dave. You may begin. Good afternoon. My name is Dave Doherty, CFO of Surgery Partners, and I'm here with our CEO, Eric Evans, and our Executive Chairman, Wayne DeBite. We appreciate you joining us to discuss our financial results for the first quarter of 2023. Today, we will make forward-looking statements. There are risk factors that may impact those statements and could cause future results to be materially different from them. These risk factors are described in this afternoon's press release and the reports we file with the SEC. which are available on our website at surgerypartners.com. The company does not undertake any duty to update these forward-looking statements. In addition, we will reference certain financial measures that are considered non-GAAP, which we believe can be useful in evaluating our performance. The presentation of this information should not be considered in isolation or as a substitute for results prepared in accordance with GAAP. These measures are reconciled to the most applicable GAAP measure in this afternoon's press release. With that, I'll turn the call over to Wayne. Wayne?

Thank you, Dave. Good afternoon, and thank you all for joining us today. I'm pleased to report Surgery Partners' first quarter adjusted EBITDA of 90.1 million, 17% higher than last year's first quarter, which generated an adjusted EBITDA margin that grew 60 basis points to 13.5%. Including our non-consolidated facilities, we performed approximately 176,000 surgical cases in the first quarter, 12% more than 2022 with contributions from all our core specialties consistent with our expectations. This strong case growth combined with increased acuity and contributions from recent acquisitions generated net revenue of $666 million. Consistent with our prior quarters, our first quarter results demonstrate top line growth, organic margin expansion, and contributions from recent acquisitions which are the cornerstone of our long-term growth algorithm. Dave will share more details regarding our financial results, but let me highlight a few. Net revenue of $666 million represents nearly 12% growth from the prior year, with same facility revenue growth of 10.3%. This organic growth rate was a combination of case growth of 5.3% and net revenue growth of 4.8 per case. As we pointed out in prior quarters, the case mix of our business has been stable since early 2022, with all specialties growing at rates consistent with our expectations. Physician recruiting efforts yielded nearly 150 new surgeons in the first quarter, representing all of our core high-growth specialties. As we start the year, we continue to be encouraged by the quality of physicians that choose our high-quality surgical facilities. We anticipate recruiting approximately 500 to 600 new physicians annually, Our prior year recruiting cohorts continue to demonstrate strong year-over-year growth, with first quarter recruits from our 2022 cohort generating 78% more revenue in the current year quarter as compared to the same period last year. Finally, joint replacements in our ASCs increased 84% since the first quarter of 2022, as we continue to focus on the significant shift in site of care in our recruiting efforts, acquisitions, and de novo investments. Our M&A team continues its disciplined approach to sourcing and executing on strategically aligned acquisitions at attractive multiples, and we finished the first quarter deploying 60 million at a sub-eight times multiple. Our M&A pipeline is robust, and our balance sheet remains strong, giving us continued confidence in our ability to meet or exceed the annual goal of deploying at least 200 million through acquisitions. As Dave will discuss in a few minutes, We also unlocked additional capital for redeployment by executing on components of our asset portfolio refresh. We will be redeploying this capital in higher growth short stay surgical facilities. Together with the board, I'm optimistic and have high confidence in both the near term and the long term growth prospects of surgery partners. As I mentioned earlier, all growth levers that support our long term growth algorithm are working as expected with top line growth, margin expansion, and prudent capital deployment. While our execution over many quarters has been strong and consistent amid a volatile environment, for the first time in years, the broader healthcare services operating backdrop feels more constructive for providers, including decelerating labor inflation, more consistent volumes across the ecosystem, and a more constructive rate environment. Off this, the strength of our first quarter and our continued investments we are raising our 2023 adjusted EBITDA to be greater than $430 million. This outlook is inclusive of the anticipated headwinds and tailwinds that Dave will discuss in more detail. With that, let me turn the call over to Eric. Eric?

Thanks, Wayne, and good afternoon, everyone. The start of 2023 for Surgery Partners has been productive as the company again delivered on its commitment for double-digit growth and continued to position the company for long-term growth. by completing five acquisitions and four divestitures, and by signing two strategic partnerships with Marquee Health Systems. Combined, these actions position us well to not only deliver on our updated outlook for 2023, but also on our long-term double-digit adjusted EBITDA growth trajectory. Dave will discuss the details of our financial results and the drivers of our increased guidance, and I will dive deeper into our operations and the portfolio changes we are making this year. From an operational perspective, our specialty case mix is right where we want it to be, and volume was in line with our expectations with over 151,000 consolidated surgical cases in the quarter, 6.1% more than last year. Let me reiterate what we shared throughout 2022. The effect of the pandemic on our results is completely in the rearview mirror. Since 2019, each of our specialties and subspecialties have experienced growth consistent with or exceeding our long-term growth. To put a finer point on this, since early 2022, all our specialties recovered from the pandemic with strong growth rates throughout the year. In aggregate, our quarter one case volume inclusive of 2023 has a four-year CAGR of 4.9%. In the quarter, our same facility growth exceeded 5% when compared to the first quarter of 2022, continuing our consistently strong growth trajectory. As Wayne mentioned, this case growth included contributions from higher acuity cases, which helped our same facility net revenue per case increase almost 5%, and combined to provide a double-digit same facility revenue increase in the quarter. We expect to continue to see both volumes and rate growth in excess of our long-term guidance ranges throughout 2023. Labor and supply costs remain well under control, allowing our adjusted EBITDA of $90.1 million to generate 13.5% adjusted EBITDA margin, 60 basis points of expansion compared to last year. Physician recruiting, which targets the highest quality physicians, added approximately 150 physicians in the quarter. As Wayne highlighted, each of our recruiting cohorts continues to drive strong year-over-year growth, and we are encouraged by the early strength of the 2023 recruiting class. All of this has continued to fuel our growth in MSK procedures, particularly total joint cases in our ASCs. We performed over 26,000 orthopedic procedures this quarter, and the volume of total joint surgeries that shifted into our ASCs increased by 84%. And as we have discussed, we are preparing for the next wave in cardiac procedures that we expect to migrate to outpatient settings, starting in earnest over the next three to five years. We do not expect the shift of these orthopedic and cardiac procedures to slow down, and we continue to position our portfolio to take advantage of this high growth opportunity. In the first quarter, we deployed $60 million acquiring two new ASCs and increasing our ownership position in three other facilities, including two from a prior year minority interest acquisition from Value Health. These acquisitions, which increase our multi-specialty capacity, have an average purchase price multiple of less than eight times trailing 12 months earnings. We are rapidly integrating these acquisitions into our operations and expect to yield further earnings from our operating system synergies in the first 12 to 18 months post-acquisition. On the de novo front, since 2019, we have opened four new ASC facilities and have 10 fully syndicated de novos under construction. Many of these projects are slated to open in late 2023 or early 2024. These facilities include consolidated and minority interest ownerships and our multi-specialty with a concentration in orthopedics. In addition, as we mentioned in prior calls, we consistently evaluate our portfolio of approximately 150 short-stay surgical facilities to ensure we are the best owner of the assets and that they meet our high expectations for both growth and margin performance. Although each of our facilities generate revenue and earnings, in certain cases, the monetization and redeployment of the proceeds of our portfolio management efforts will be net accretive to the company's earnings. Year to date, we have divested our interest in four facilities and expect to divest of another four to six facilities by mid-year. The aggregate proceeds from these divestitures will be redeployed at a lower multiple and will be accretive to future earnings. Our pipeline of new acquisition opportunities remains strong and supportive of our commitment to deploy at least $200 million plus the incremental proceeds from divestitures this year. Finally, I'm pleased to announce new strategic partnerships with two prominent health systems. Intermountain Health, and Ohio Health. While decades of growth remain in our core business of two-way JVs with surgeons, Surgery Partners has emerged as a partner of choice for hospital systems, revisiting their outpatient strategy. We are winning in this area because we are differentiated in our ability to consistently drive same-site growth through data-enabled physician recruiting. We bring a rigorous and disciplined approach to facility management, including on labor and supply costs. and more recently, our proven de novo capabilities at scale. Our deep operational excellence stands out. Accordingly, Intermountain and OhioHealth are like-minded health systems that are joining with us on a long-term growth strategy, supporting the country's migration of procedures into the highest value setting. Through these partnerships, we will combine Surgery Partners' industry-leading management expertise with the strong market reputation Intermountain Health has earned throughout the mountain region, spanning Nevada to Montana, and the equally strong reputation Ohio Health has earned in Ohio to create regional ASC networks. Specifically, in partnership with Intermountain, we will provide management services for 19 current and future ASCs in the Utah and Idaho markets. We will also partner with Intermountain to co-develop additional ASCs throughout their regional footprint in the years to come. Surgery Partners is now also the partner of choice with Ohio Health as it accelerates its plans to create a statewide ASC network in Ohio. In this partnership, we will provide management services to ASCs that we jointly acquire or develop in the coming years. These partnerships with like-minded health system partners represent significant opportunities to serve these growing communities and to expand our scale. Although they will provide minimal earnings in 2023, we expect rapid and material contributions to our growth story over the next several years. We look forward to sharing more details about these developing ASC networks throughout the year. In summary, I am very proud of the team's accomplishments this quarter. Not only have we continued to excel within our core operations as evidenced by our consistent financial results, we are executing on our commitment to position the company's footprint for long-term growth and success. More than ever, our company provides a cost-efficient, high-quality, and patient-centered environment in purpose-built short-stay surgical facilities that provide meaningful value to all of our key stakeholders. With that said, I'm going to turn the call over now to Dave to provide additional color on our financial results as well as our 2023 outlook. Dave?

Thanks, Eric. My initial remarks will focus on our first quarter financial results before providing additional perspective on our outlook for the remainder of the year. Starting with the top line, we performed 151,000 surgical cases in the first quarter, which is 6.1% more than the prior year first quarter. These are only cases that are included in our consolidated revenue. If I include cases performed at non-consolidated facilities, we performed 176,000 cases. These cases spanned across all our specialties with an increasing focus on higher acuity procedures, which is reflected in our double-digit same-facility revenue growth this quarter. The combined case growth in higher acuity specialties, specific managed care actions, and the continued impact of acquisitions supported revenue growth of 11.7% over last year to $666 million. I will reiterate that an increasing share of recent acquisitions include minority interest investments. For these acquisitions, revenue is not included in our consolidated financials. We will continue to be agnostic to the accounting treatment of the assets we acquire. Our focus remains to acquire high growth high-quality assets aligned with our targeted specialties at the most favorable multiple possible. This may affect how some of our stakeholders model revenue expectations, so it is worth reiterating this point for you. From a financial planning perspective, we focus primarily on growing our adjusted EBITDA and managing the core operations to grow market share. On a same facility basis, total revenue increased 10.3 percent in the first quarter. with case growth at 5.3%. Net revenue per case was 4.8% higher than last year, primarily driven by higher acuity procedures. As we reported throughout 2022, our prior year results were largely unaffected by the pandemic and the inflationary pressures that affected prior years. Hence, the first quarter of 2022 is a stable comparable period for this year. Adjusted EBITDA was $90.1 million for the first quarter, giving us a margin of 13.5%, a 60 basis point improvement over last year, and in line with our expectations of continued margin expansion. Inflationary pressures related to labor and supply costs have almost completely moderated in the first quarter, but we will remain vigilant in monitoring these factors across our portfolio. The costs of salaries, wages, and benefits as well as our medical supply costs were consistent with prior periods as a percentage of revenue. As we noted in the past, we expect to produce at least $140 million of free cash flow in 2023. We define free cash flow as the operating cash flow we report in the statement of cash flow, which is net of our cash interest expense, less the distributions paid to our partners and capital expenditures at our facility. In the first quarter, we generated free cash flow in excess of 20 million, which is in line with our expectations. There were no unusual items that affected this metric. We remain confident in the ability to meet our target of at least 140 million in 2023. We ended the quarter with 246 million in cash and an untapped revolver of 553 million. When combined with the free cash flow we are generating, We believe our current and future liquidity positions us well in this macroeconomic environment while giving us flexibility to maintain our long-term acquisition posture of deploying at least $200 million per year for M&A. As a reminder, our corporate debt is less than $1.9 billion. As a part of our consistent, proactive approach in managing our balance sheet, including future interest rate exposure and long-term liquidity, Prior to the current macro environment, we entered into a number of interest rate swaps and fully hedged the interest cost of this debt, which averages at a fixed rate of 6.7%. Accordingly, we are not exposed to significant rate risks, which is another factor giving us confidence in our free cash flow growth. Our first quarter ratio of total net debt to EBITDA, as calculated under our credit agreement, was 4.3 times. With the earnings growth we expect, we are confident this ratio will decline over the year. In the first quarter, we deployed $60 million on five transactions at a sub eight times multiple. The facilities we invested in are primarily focused on MSK procedures and are well positioned to support and strengthen our same facility growth trends in future years. Additionally, as mentioned in prior calls, We continually refresh our asset portfolio to align with long-term market growth trends. Year-to-date, we have divested four lower-performing facilities and expect to conclude another four to six by the middle of the year. Proceeds from these divestitures will be redeployed as incremental M&A at comparatively lower multiples with stronger future growth prospects. Combined, these divestitures will create a revenue headwind of over $100 million for 2023 prior to any redeployment of proceeds received. That being said, based on the strength of our first quarter results and our refreshed outlook for the remainder of the year, we expect to more than cover this divestiture headwind and are reaffirming our full-year revenue guide of greater than $2.75 billion. From an adjusted EBITDA perspective, We expect to more than overcome this headwind due to the strength of our top-line revenue growth and continued margin improvement throughout the year. While the timing of the vestiture and related M&A activity is a challenge to predict, we believe our 2023 full-year outlook reflects a conservative view. Carrying the momentum of our first quarter results, we remain optimistic and confident about the company's growth and are raising our outlook for 2023 adjusted EBITDA to greater than $430 million, representing at least 13% growth compared to 2022. Our financial guidance is informed by the continuation of strong organic case and rate growth, the annualization of prior acquisitions, and the timing of future M&A and divestiture activity. Contributions from our in-process de novos including the continued maturation of the community hospital we opened in Idaho during the pandemic. Regarding the exciting new health system partnerships that Eric mentioned, we expect marginal benefit to our results this year, with more significant growth in adjusted EBITDA in 2024 and 2025. Given the nature of these partnerships, most of these earnings will be earned through management fees and minority interest earnings. As a reminder, Our business has a natural seasonal pattern largely driven by annual deductibles resetting for commercial payers that tend to skew our results lower in the first quarter and higher in the fourth, relatively speaking. We continue to anticipate the seasonal pattern of our results will be consistent with 2022, with second quarter adjusted EBITDA to be approximately 23% and revenue to be approximately 24% of our full-year guidance. Our first quarter results speak to the strength of our operations and our business model, and we believe that the balance of the year should continue to capitalize on that momentum. With that, I'd like to turn the call back over to the operator for questions. Operator? Thank you. We will now be conducting a question and answer session. If you'd like to ask a question, please press star 1 on your telephone keypad. The confirmation tone will indicate your line is in the question queue. You may press star 2 if you'd like to remove your question from the queue. For participants using speaker equipment, it may be necessary to pick up your handset before pressing the start key. One moment, please, while we poll for questions. Thank you.

Our first question is from Jason Castorla with Citi. Please proceed with your question.

Great. Thanks for taking my questions. Just on the volume front, certainly a solid number in the corner of 5.3. But I was hoping you could give us a flavor of how payer mix trended. And then just given a macro backdrop, if any portion of that volume was perhaps pulled forward ahead of potential coverage changes later this year, or if you think underlying demand was just more broad-based in that sense.

Hey, Jason. Thanks for the question, and good afternoon. I would say, from our perspective, we don't believe anything was pulled forward. This is the core run rate that we had anticipated. I think we're feeling fairly optimistic for the full year, continue to believe that we'll see similar patterns as this year progresses, and I think as we said in our prepared remarks, we are fully expecting to exceed our typical algorithm in terms of growth.

Yeah, and I guess I'd say it is across all specialties. Certainly you saw the acuity growth was strong. We talked a little bit about our joint growth being 84% year over year. Continue to see that acuity come through. From a mixed perspective, very consistent with what we expected. So I would just say like fully meeting expectations as far as the overall growth, and we liked how evenly spread it was across all of our service lines with specifically strong growth, the higher acuity procedures, which clearly showed up in our same store net revenue per case.

Got it. Okay, thanks. Helpful. And then just maybe as a follow-up, I wanted to ask about labor costs in the quarter. You talked about inflationary impacts. It's generally moderated in 1Q. But if we isolate SWV to a per-case basis, it looks like it was up about 6.5% year-over-year. That's been growing in that mid-to-high single-digit range for the past three quarters. Maybe just help bifurcate the impact between underlying wage growth trend for 23 and the impact that the shift towards higher QE procedures has on the intensity of labor per case. That would prop that setup, too. Thanks.

Yeah, I'll dive in there. So, Jason, that's a great question. You know, we continue to see very moderate impact of premium labor. As we've talked about kind of throughout the pandemic, it's been a low percentage of our total labor. Certainly at points in the pandemic, we saw, you know, some excessive rates in that in some markets, but in general, it didn't have a huge impact in prior years. We continue, we think, to manage that cost quite well. From a per-case perspective, I think, you know, you do point out something, which is good to point out. In higher revenue cases, obviously, more higher acuity cases, You know, there certainly is some length of stay difference in cases, and it can be a different labor mix. But in total, we feel good about where labor came in. It still remains well controlled. And, you know, we think it's actually, if anything, it's moderating and continuing to look better as the year moves forward.

Great. Thank you. Thank you. Our next question is from Kevin Fishbeck with Bank of America.

Please proceed with your question.

Hi, this is Nabil Gutierrez on for Kevin. Thanks for taking the question. Can you talk about how volumes trended throughout the quarter? Was the growth consistent each month?

I would say relative to our expectations, yeah. We obviously build our January, February, March different each year. We look at the number of days, but if you look at a year-over-year basis, the number of days for us was consistent for 2022 versus Q1 of 2023. So No surprises from that. We saw pretty consistent volume each month. So, yeah, nothing weird to report.

Thanks. And then my follow-up is, what type of procedures grew the fastest?

So, as we called out, I mean, we called out total joints this quarter, growing up 84% in our ASCs. We clearly see orthopedics being a strong grower, but to be honest with you, all specialties were up. And so, you know, consistent with our expectations, we're seeing our core service lines show strength and continued market share gains. So, I think across the board it was quite good, but I would definitely note, and you can see it in our, obviously our same per case, our per case revenue increases, same facility, that we had pretty strong acuity growth, particularly in MSK.

Thanks.

Thank you. Our next question is from Brian Tankola with Jeffrey.

Please proceed with your question.

Hey, good afternoon, guys, and congrats. I guess, Wayne, you know, obviously congrats on the Intermountain deal. As I think about the surgery partner strategy, historically this was a two-way approach to running surgery centers, right? And now, obviously, you have a big partnership with a marquee hospital name. So maybe a couple things. Just thinking about the strategy, I don't want to say shift, but expansion there, like how you're thinking about that. And maybe if you can remind us, you know, what the advantage is of partnering with a hospital as well versus your legacy two-way model.

So let me just start off by saying that one of the things that Eric brought when he came in and then took over as CEO was this idea that we really thought we could make the algorithm even more additive if we would be open to some of these three-way JV partnerships. And the core to that was, you know, will they be like-minded similar to the way we see the world and who we want to align with and how we want to align? So first and foremost, super excited because this is now another growth lever for us. I'm going to ask Eric to comment, though, since this was a big part of his brainchild as we were thinking about the strategy of where we wanted to take this over time. And more importantly, maybe use Intermountain as an example of how this like-mindedness works.

Yeah, Brian, first of all, thanks for the kind words. We were excited about the quarter and excited about the start of the year. partnership and the Ohio Health Partnership, both are quite exciting for us. Obviously, two really well thought of systems. You know, you keyed in on Intermountain. You know, one thing that makes that partnership so aligned with the way we see the world is Intermountain also has a large payer arm. And, you know, when you have a payer arm like that, they see the world from a highest value, highest use, you know, case as well. And so we naturally align with their thinking on how they want to move in the world and really help this transition to higher value cases. Clearly, they have choices when they choose a partner. We feel like we bring best-in-class operational capabilities, the ability to grow their facilities. And so we're excited initially starting with helping them manage their already kind of strong position in the state of Utah, but more importantly, investing together to grow across the Mountain West. So as Wayne mentioned, this is additive to our growth algorithm. We're going to continue to be a very strong two-way partnership company, as we always have been. But these three-way partnerships, we do think, expedite our ability to grow in certain markets where we have not been as quick to grow. And they also, we think, unlock a lot of potential to continue the acuity increases in those regions. So super excited about it. Intermountain, again, like-minded in the way that what they really believe is they want to deliver the best quality, lowest cost, high-value procedures and care in general to their patients. And we're a natural partner when that's their mission.

I appreciate that. And then I guess maybe for Dave, as I think about revenue per procedure, obviously pretty strong, and I know some of that is mixed. Is this the right kind of like level of growth in revenue per procedure that we should be thinking about going forward, considering that you're obviously seeing a lot of growth in MSK or joint replacements?

Yeah, yeah, Bryce, great question. And I think it goes back to the baseline that you've set for 2022 going into 2023. The premise there is that we were hitting in all cylinders last year, and the growth that we're seeing inside this as we start the year is going to be consistent with that. So I think it's a fair assumption that we're going to be at the upper end of that long-term guidance range as we go throughout the year. There's nothing indicating that we had an odd year in any of the quarters last year, and certainly as we look forward into this year, we've seen pretty solid.

Awesome. Congrats again, guys. Thank you.

Thank you, Brian. Thank you. Our next question is from Bill Hendricks with RBC.

Please proceed with your question.

Hey, guys. Thank you very much. I just wanted to follow up on that last one again with the 4.8 revenue per case on the same short basis, clearly above the regular 2% to 3% algorithm, and you talked about acuity. But you'd also mentioned last quarter some upside from kind of folding some of your newer acquisitions into your managed care relationships. in some of your markets. I wanted to know if maybe that had some influence, too, and how can we think about that, especially with some of the new acquisitions and partnerships you've formed this quarter? Thanks.

Hey, Bill. This is Wayne. First and foremost, we require all acquisitions to lap an entire year before we will even evaluate them for same store. From our perspective, We think that gives you the purest view of how we're doing. And so we actually don't benefit from M&A until we show the value we can actually bring a year later. So the good news is this is a real pure view of same store. And we would expect these trends to continue. I mean, at least based on our forecast for the year and how we see things, I think we're going to consistently outperform both on the volume and on the rate side. So as you think about historically, the upper end would have been that 6% same store kind of revenue. We think you're going to continue to see us outperform that throughout the year, and we're going to finish much higher than that for the full year.

Thank you. Thanks, Bill.

Thank you. Our next question is from Lisa Gill with J.P. Morgan. Please proceed with your question.

Thanks. Great. Thanks very much. Good afternoon. I also just want to focus for a minute on the partnerships. One of the things that stood out to me is that Ohio Health also has a relationship with Privia. You announced last year a relationship with Privia. So my first question is, do you see incremental opportunities to partner alongside Privia as they continue to sign on these physician groups? And then secondly, I know you said not much contribution here in 23, but ramping into 24 and 25. Is there any way, Dave, to maybe give us an idea of how to think about how that ramps, and are there any implementation or startup costs that will be in 23?

So, Lisa, I'll start with kind of your first question, and I'll turn it over to Dave to talk a little bit about kind of future, I don't know how much guidance he'll give on that, but we can talk a little about directional stuff. When it comes to the relationship with Privia, you know, look, we have said before that Privia and companies like them that are in the payvider space naturally align well with what we're doing. So I definitely think it's not surprising that a partner we would choose would also choose to partner with kind of those value-based primary care groups. That certainly aligns well for us to grow together. So we can see lots of markets where that's a real potential synergy, not just with Privia, but Village MD, Oak, anyone who really has a primary care group that is either capitated or value-based, we look at that as a real benefit. And I think OhioHealth, you know, having those kind of partnerships in the primary care side just reiterates that they're a like-minded partner, really thinking about, you know, driving value, making sure patients get to the right place, and growing the healthcare system in a very thoughtful way.

Yeah, Lisa, on your question on kind of how you're going to see this coming through our results this year, you know, it is a ramp that we're going into these facilities kind of on a very deliberate basis. So as we migrate into these relationships were being very thoughtful about that. So first and foremost, that's how the ramp-up kind of happens for us. You know, we do expect this to be slightly positive to the company's earnings this year, inclusive of any of the startup costs that are inside there. So there is a slight positive benefit that we've baked into our updated outlook for the year. Okay, great.

Thank you.

Thank you. Our next question is from Whit Mayo with SDB Security. Please proceed with your question.

Hey, thanks. Good afternoon. Just want to make sure I get this right on the hospital partnerships. I think this is correct, but Ohio Health is not contributing any of their existing ASCs into a joint venture with you initially, correct?

Hey, Whit, that's correct. I do think one of the things that we try to do with any partner as we As we show our value, we think there could be opportunities in the future to earn that business as we show what we can do across the state, but that is correct from the start. We will be looking at new offensive opportunities together.

Okay, perfect. That's helpful. Dave, you mentioned that you spent $60 million on acquisitions. The cash flow statement has 40 net of cash. I presume that that's just net of the divestitures. Do I have that correct, and is it safe to say that you received $20 million from roughly for those asset sales?

Yeah, no, I don't think that's a safe assumption. I think that cash flow statement is net of the cash acquired as we go into that, as well as any assumption of debt, the mechanics, I think, of just how that shows through. I can walk you through that a little bit later.

No, no, no, that's fine. You spent 60. Okay, I got it. One last one, just want to make sure from a modeling perspective, I get this right, of the I think you said you plan on selling $100 million of revenue, and I presume a portion of that has already closed. There's more to come. Is all of that consolidated today? Is any of it coming through equity earnings? I just want to make sure that we get our models right. Thanks.

It is all consolidated today. When we initially modeled, we assumed a mid-year convention in terms of when we would sell these, very similar to how we assume on acquisitions. So it does create a headwind for us. The full headwind's not the $100 million. Think about it being about half of that is the actual headwind versus our original guide, but based on the strength and the quarter, we're more than lapping that.

Okay, okay, but $100 million annual, but $50 million as you think about a mid-year convention relative to the guidance. And then one last one, just as you look at the development pipeline and the acquisitions that you will close, should we expect any of those to be consolidated?

Yeah, absolutely. We'll continue to look at any and all models. We've said this, we're pretty agnostic to the structure as long as we have to manage it, we have to feel good about the growth prospects and what we can bring to it. But yes, we will continue certainly to buy consolidated positions. What I would say is with the health system partnerships, you're more likely to have non-consolidated positions, certainly with those going forward. Typically with de novos, you'll often start in a non-consolidated position, but will buy up over time. And so I think it's going to be a healthy mix with, and we'll continue to give really good guidance to you guys so you guys can think about the revenue impacts. As we've said before, we're agnostic to structure. Our job is to grow EBITDA, grow market share, grow cases. And whatever structure makes the most sense for us to expedite that, we're going to take. Awesome. Thanks. Yep. Yep.

Thank you. Our next question is from Bill Sunderland with the Benchmark Company. Please proceed with your question. Close enough. Hey, guys. Nice quarter. Can you go back and just in the quarter you said four de novos, I think, and 10 value health consolidation? Was that correct?

Yeah, Bill, just a... So we've recently completed four de novos, and we've got 10 that are underway that are fully syndicated. We have a lot more than that in the pipeline. I'm glad you asked about this. I will say this is another additive opportunity to our growth algorithm. When you think about how we think about the business, there is no reason we shouldn't be double-digit syndicated new de novos annually moving forward. Really strong pipeline, and we're excited about those partnerships, in particular because they're a really heavy ortho.

Yep. And could you update us on the value health relationship, kind of where you stand with facilities and development plans?

Sure. Yeah. So value health, we've had a number of facilities. I don't have the full numbers in front of me, but Bill, we'll follow up with that. We've acquired a fair amount of facilities that were existing facilities that have been added into our portfolio, some of which we've actually bought up to a consolidating position already. We continue to, you know, work with them on new de novos. Many of those 10 we just talked about are value health partnerships that we've worked on together. So certainly that's been a really impressive part of our partnership. And they continue to work on their, you know, their bundled health model and their value-based care pricing for hyper-specialties in orthopedics and cardiology, bariatrics. We are pursuing opportunities in those in multiple areas. And, you know, We're going to continue to push forward on that. As you can imagine, that's part of the value-based world that is pretty nascent, but there's real opportunities. We're seeing it in certain of our centers already, and we hope to see that grow in the future. Great.

And then you've got a lot on your plate, but are you potentially in discussion or are you in discussions with potentially other health system relationships? Yes.

So Bill, it's a great question. I mean, look, we've been in discussions for the last couple of years. We've got a lot of health systems interested in talking to us. Some of those are less interesting to us than it might be them to partner with surgery partners. So we've had to be very picky on who we choose. But yeah, no, I think you should anticipate there will be additional health system partners as we move forward. We're going to be very disciplined on that and make sure when we do choose those, they're going to be a great partner over time to significantly move the needle on our value-based goals and really driving value within healthcare. So, appreciate that question, Bill, and it's certainly a new additive growth lever that we're excited to keep pushing on.

Got it. Thanks again.

Thank you. Our next question is from Steven Vallecat with Barclay. Please proceed with your question.

Great. Thanks. Good afternoon, everyone. So you guys mentioned that the 60 million in acquisitions completed in the first quarter had an average multiple of just under eight times. And the, the deals were focused mainly on MSK procedures. I guess I'm curious, can you just remind us how this you know, the sub eight X multiple just stacks up versus recent history on acquisition multiples and also with the overall ASC industry seeming to have a pretty strong year of potentially accelerating growth in 2023. Just curious if the industry strength is expected to have any impact on the acquisition multiples as the full year progresses, just based on the pipeline of additional deals that you're evaluating now. Thanks.

Hey, Stephen. Let me first start by saying we have not seen multiples change, nor would I say on our current pipeline are we seeing them change in this environment, which is encouraging. I would also highlight that when we discuss multiples, we are using actual trailing 12-month EBITDAs, so we do not give you synergized multiples. So if you look at our sub-8, that's been our track record for the last five years. If you look at even last year, the multiples for the entire year remained sub-8 as we aggregate them. And for the current year, I don't see those trends changing. So from our perspective, as we've always said, the M&A is lumpy, and we're going to be very disciplined in what we approach and how we approach it. but we're super encouraged, and the pipeline is strong, and I would expect us to continue to announce more acquisitions throughout the year and potentially exceed our $200 million.

Yeah, and Stephen, I just had a couple of things I had on there. Just a reminder, you know, not only do we buy at sub-8, trailing 12, but in the first 12 to 18 months, our operating system's job is to take a turn, turn and a half off that. So that's our starting point. When you talked about, first of all, you also commented on the strength of the industry. I'd just like to say we're all excited about that. It's not surprising to us. There's a lot of A lot of great companies in our industry, we're seeing that growth return because it is such a great marketplace. I don't think that's going to change the multiples, but certainly we think high-quality assets are still going to be kind of in that range. And as Wayne said, it's been quite consistent. We continue to be excited about what that pipeline looks like.

All right.

That's helpful. Thanks. Great. Well, listen, as we conclude, I would like to recognize the significant efforts and commitment to excellence of our over 12,000 colleagues and nearly 5,000 physicians. We take to heart the responsibility for providing the best environment for physicians to perform exceptional procedures of the highest clinical quality and the privilege that we have to serve over 600,000 patients in what are often their most vulnerable moments. I'm very, very proud to work alongside my many talented colleagues and professionals as we work to deliver on our mission more fully, which is to enhance patient quality of life through partnership. Thank you for joining our call this afternoon, and I hope you all have a great day.

This concludes today's conference.

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