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Operator
welcome to the hca healthcare fourth quarter 2021 earnings conference call today's call is being recorded at this time for opening remarks and introductions i would like to turn the call over to vice president of investor relations mr mark kimbrough please go ahead sir all right thank you chris uh good morning and welcome to everybody on today's call uh with me this morning is our ceo sam hazen and cfo bill rutherford
Sam
along with our Chief Medical Officer, Dr. Michael Cuff, and Frank Morgan, our new VP of IR. Welcome, Frank. Glad you're here. Sam and Bill will provide some prepared remarks, and then we'll take questions. Before I turn the call over to Sam and Bill, let me remind everyone that should today's call contain any forward-looking statements, they are based on management's current expectation Numerous risk, uncertainties, and other factors might cause actual results to differ materially from those that might be expressed today. More information on forward-looking statements and these factors are listed in today's press release and our various SEC filings. On this morning's call, we may reference measures such as adjusted EBITDA, which is a non-GAAP financial measure, a table providing supplemental information on adjusted EBITDA and reconciling net income attributable to HCA Healthcare, Inc. is included in today's release. This morning's call is being recorded, and a replay of the call will be available later today. With that, I'll now turn the call over to Sam.
Michael Cuff
All right, thank you, Mark, and good morning, and thank you for joining us. As we begin this call, I want to reflect on 2021. Across many dimensions of our business, Our teams demonstrated an impressive ability to adjust quickly and effectively to three different surges and deliver for our patients, deliver for our communities, and deliver for each other. This steadfast resolve and sacrifice to serve others are what make healthcare workers special people in general, but specifically for HCA Healthcare, they are what make our company great. I want to thank our colleagues and physicians for their outstanding work this past year. In the fourth quarter, the COVID pandemic once again altered course with the Omicron variant. As the Delta variant surge was slowing down at the end of the third quarter, with some spillover into the fourth, the Omicron surge started to influence our business in early December. Overall, our teams continued their tremendous response, and the effects of the pandemic's ever-changing conditions were managed well as reflected in our financial results for the fourth quarter. which were solid and in line with our most recent guidance. In the quarter, our hospitals provided care to 27,000 COVID-19 patients, approximately 5% of total admissions. This level is significantly below the third quarter's 13%. Since the beginning of the pandemic, we have provided inpatient care to over 260,000 patients who contracted the virus. Currently, our hospitals continue to treat many patients with COVID-19. COVID-related census levels fortunately have begun to peak, and we anticipate they will decline over the next few weeks. Same facility revenues grew 6.4% in the quarter as compared to prior year. Inpatient revenue grew 2%, and outpatient revenue grew 13%. Same facility volumes increased on a year-over-year basis across most major categories. with the exception of inpatient surgeries, which were down 1%. In a challenging labor market, our teams adjusted well. Labor costs created some pressure on margins as compared to last year, but sequentially, there was no significant change in this metric as compared to the third quarter. Adjusted EBITDA margin for the quarter was strong. Diluted earnings per share, excluding gains on sales of facilities, increased 7% to $4.42 in the quarter. As we move into 2022, our overall outlook for the year remains generally consistent with the early perspectives we provided in last quarter's call. While certain aspects of our business, including the impact of the pandemic, remain difficult to predict, we believe the guidance that we are providing today is reasonable. We also believe that the combination of our discipline to operating culture plus our growth plan and the strong support from our capital deployment program should help us deliver the results we are forecasting for the year and enhance long-term shareholder value. As I indicated previously, we believe demand for healthcare services will be strong in 2022 and comparable to historical growth rates in the 2% to 3% zone with COVID-related admissions representing between 3% and 5% of total. We expect this demand to be supported by a growing economy and more insurance coverage for people through their employer or the exchanges. We believe HCA Healthcare's strong and diversified portfolio of markets is differentiated across the industry and presents numerous long-term growth opportunities. Because of this, we plan to continue investing in our core strategy of developing our provider networks through our capital spending plan and also through acquisitions, when available, acquisition that we completed at the end of the year in South Florida. These investments continue to add depth to our networks and convenience for our patients, creating an easier and more cost-effective accessibility for our healthcare systems. Over the past year, we have increased the ambulatory care sites in our networks by 14%, bringing the total number to approximately 2,200. These sites support the 182 hospitals we operate today and will provide support in the future to the eight new hospitals we recently announced in various Texas and Florida markets. As I mentioned, we are operating in a difficult labor market. Over the past year, we have invested in our colleagues with increased pay, supplemental bonus programs, and additional benefits. These investments coupled with our efforts to improve operational support for providing care should help us mitigate some of the difficulties caused by this environment. These past two years certainly have been a strain on our people. But through it all, they have demonstrated a level of excellence, compassion, and resilience that has strengthened the company in many ways. They have accomplished this while simultaneously staying true to our mission and better positioning us for continued success. With that, I'll turn the call over to Bill for more details on the quarter's results, our 22 earnings guidance, and capital deployment plan. Thank you.
Mark
Okay, great. Thank you, Sam, and good morning, everyone. I will provide some additional comments on our performance for the year, then discuss our 2022 guidance. Our cash flow from operations was $2.4 billion as compared to a use of cash of $3.6 billion in the fourth quarter of 2020. In the prior quarter, cash flow was affected by our returning or repaying early approximately $6 billion of CARES Act funding. For full year 2021, cash flow from operations was just under $9 billion. Capital spending was $1.2 billion for the quarter and was $3.6 billion for the full year 2021. In addition, we have approximately $4.1 billion of approved capital in the pipeline that is scheduled to come online over the next three years. We completed just over $2 billion of share repurchases during the quarter and $8.2 billion for the full year. Our debt to EBITDA ratio was 2.7 times at the end of the third quarter, and we had approximately $3.6 billion of available liquidity at the end of the quarter. For full year 2021, we realized approximately $2.2 billion in proceeds from sales of facilities and healthcare entities, and recognized approximately $1.6 billion in gains on these sales. We also executed on 1.1 billion of acquisitions on healthcare entities during the year. As noted in a release this morning, we are providing full year 2022 guidance as follows. We expect revenue to range between 60 billion and 62 billion. We expect net income attributable to HCA Healthcare to range between 5.55 billion and $5.835 billion. We expect full year adjusted EBITDA to range between $12.55 billion and $13.05 billion. We expect full year diluted EBITDS to range between $18.40 and $19.20. And we expect capital spending to approximate $4.2 billion during the year. So let me provide some additional commentary on our guidance. The midpoint of our adjusted EBITDA guidance of $12.8 billion reflects a 1.2% increase over our 2021 adjusted EBITDA. In 2021, we recognized approximately $900 million in COVID support from the DRG Adams, HRSA reimbursement for uninsured COVID patients, and the impact of the delayed sequestration cuts. We do not have full line of sight into all these programs for the full year, but we do expect some benefit continuing, and our guidance anticipates approximately $150 million of support in 2022. In addition, our divestitures contributed about $140 million of adjusted EBITDA in 2021. When you consider these items, along with an estimate of about $300 million of incremental costs for serving COVID patients in 2021, our growth in adjusted EBITDA is consistent with our historical expectations for growth over time of 4% to 6%. Within our guidance, we expect our same facility admissions to grow approximately 2% to 3%, our revenue per admission to grow approximately 1%. We anticipate outpatient revenue to grow in the mid to high single digits. We anticipate adjusted EBITDA margin to range between 20% and 21% for the full year. Depreciation is estimated to be about $3 billion, and interest expenses projected to be around $1.7 billion. Finally, our fully diluted shares are expected to be about $303 billion for the full year. Cash flow from operations is estimated to range between $9 billion and $9.5 billion. As also noted on release this morning, our Board of Directors has authorized a new $8 billion share repurchase program and declared an increase in our quarterly dividend from $0.48 to $0.56 per share. So with that, I'll turn the call over to Mark to open it up for Q&A.
Sam
All right. Thank you, Bill. Thank you, Sam. Chris, would you provide instructions on the queue for questions and questions? Remind everyone to limit their questions to one, please, so that we can get as many people on the call as possible.
Operator
Certainly. And as a reminder, if you would like to ask a question, please press star 1 on your telephone keypad. Our first question is from Anne Hines with Mizuho Securities. Your line is open.
Anne Hines
Hi, Greg. Good morning. Just a couple of, how are you? Just a couple of questions. So when I look at inpatient and outpatient versus 2009, they're down roughly 5%, which is a deterioration from prior quarters. Can you tell us what's driving that? Is it, I mean, obviously it's staffing issues. So maybe what's driving it, staffing issues versus COVID spikes and you're turning people away versus maybe a change in patient behavior. And then a quick clarification on your 2021 to guidance. I think you said for 2021, you had about $300 million of incremental cost for COVID. Can you tell us what that is embedded in guidance for 2022? That'd be great. Thanks.
Sam
Anne, you were breaking up a little bit on your first question. The second, I think we all understood. The first, did anyone get that? Can you repeat that, Anne, please?
Anne Hines
Sure. So when I look at inpatient and outpatient, trends in Q4 versus Q4 2019, they were down roughly by 5%, which is a slight variation from prior quarters. So can we just get some more color what's driving that? I mean, I know there's staffing issues. Are you not able to admit patients because of staffing issues? Or is it you're turning patients away because of COVID spikes? Or is it maybe a change in patient behavior? So if you can provide some color on that versus 2019.
Michael Cuff
I think a couple of high-level observations that we believe are indicative of the fourth quarter of 2021 versus the fourth quarter of 2019. Obviously, we were carrying over into the fourth quarter a little bit of the Delta variant, and that was influencing some activity in some markets, and we think that had some impact on the 2019 comparison. The second item would be that overall we didn't see the same seasonality bump that we typically see in the fourth quarter. Again, we think that was influenced by the two different surges that were ramping down and ramping up. And then the third observation would be that on our inpatient activity, we have seen some migration in inpatient orthopedic surgeries primarily and outpatient, and that did influence the inpatient stat and propped up the outpatient stat somewhat with respect to surgeries. So those would be the three main drivers, I think, of the comparisons. All in all, we did have to manage some capacity in certain situations, again, because of the COVID markets, and we're hopeful, again, as we wind down the Omicron variant, that we can get back to some normal period of business. Again, in the 2021, as I said on our third quarter call, we really haven't had a normal run of what our business trends would be. We've had a holiday variance at the end of 2020 carried into 2021. We had the Delta variant in the middle. We had maybe three to four months where we could say there was no COVID influence of any significance. So we're making some judgments around those variations, but that would be the three-level observations we have on the 2019 comparisons.
Mark
Yeah, and Ann, this is Bill on your second question regarding the $300 million of incremental costs. That would be above and beyond what we're anticipating next year. We wanted to highlight the fact that we are seeing some decline in COVID support and acknowledge that we would also expect to see some decline of some of that direct incremental cost. So that is above and beyond what we would expect.
Sam
And that would include drug-related PP&E and some other costs associated with treatment of COVID patients.
Anne Hines
Great. And congratulations on your retirement, Mark.
Sam
Thank you, Ann. Appreciate it. Chris?
Operator
Our next question is from Kevin Fishbeck with Bank of America. Your line is open.
Kevin Fishbeck
Great, thanks. Yeah, it seems like HCA feels a little bit more controversial today than I'm used to it being, predominantly around, you know, where the margins should be normalizing out to. Obviously, this year, you're looking for lower margins than last year, but it's still nicely up from where 2019 was. Can you just level set for us, you know, where do you think ultimately those margins normalize into 2023 and beyond? And to the extent that it's above, you know, the 19 and a half in 2019, can you help us bridge what has gotten better sustainably, you know, from where you were pre-COVID? Thanks.
Mark
Thanks, Kevin. Yeah, Kevin, this is Bill. I'll make a shot at that. So as you heard in our commentary, we expect margins to land between 20 and 21%. Obviously, as we know and we've talked about during this COVID period of time, especially when you compare it to pre-COVID, we've seen a growth in acuity as we've seen people return to have higher intensity of services. And we've lost a little bit of the lower acuity business during this period of time. And we've enjoyed a favorable payer mix as we've seen, you know, a full employment effort, the activity in the health insurance exchanges. And so we saw, obviously, significant growth over the past, call it six quarters, since the middle of 2020. We expect those trends to remain positive, but maybe not at the same level. That's helping drive some of the margins that we're seeing currently. I think our view is that, coupled with other efforts HCA has, that we should be able to land within the ranges we provided.
Kevin
Is that the right long-term as well?
Michael Cuff
Well, based on what we know today, there's no reason to presume we can't sustain somewhere in that range. But obviously, there's a lot of variables to our business, and we'll have to advance our perspectives on those when we get those variables, you know, I'll say better understood over the course of this next year and so forth. But that's our thinking. We've had a number, Kevin, of financial resiliency initiatives, and we have ongoing initiatives that we think are positive to margin, all things being. equal, but we'll have to wait and see how some of these other components of our business develop over the course of 2022. All right, great. Thank you. Thank you, Kevin. Appreciate it.
Operator
Our next question is from Andrew Mock with UBS Technology. Your line is open.
Andrew Mock
Hi, thanks. I just wanted to echo congratulations to Mark on your retirement. On the 2022 guide, I want to make sure I understand the progression and development of the guide since the 3Q earnings call. Are you saying that since 3Q, you're now expecting more COVID patients, and because government relief only gives us line of sight through April, you're planning for significantly higher level of COVID costs in 2022, but only one quarter of extended government relief, such that there's somewhat of a mismatch in COVID costs and COVID relief in 2022?
Mark
Thank you, Andrew. Yeah, I mean, I think our guidance is very consistent with what our third quarter commentary is. I mean, there's obviously a lot of moving parts. I think the COVID volume we're anticipating now, as Sam mentioned, between 3% to 5% is consistent with where we thought COVID volume would be when we provided our third quarter. The COVID support programs that we mentioned, I think, are pretty close to what we anticipated during that discussion. So, you know, without talking about the... the progression of those occurring during the year. I think overall our guidance is very consistent with what our commentary and what our beliefs were at the end of the third quarter.
Operator
Got it. Okay.
Kevin
Appreciate it.
Operator
Our next question is from Justin Lake with Wolf Research. Your line is open.
spk17
Thanks. Obviously first, Mark, thanks for everything over 20 years. Enjoy your retirement. You'll be missed. Then from a question perspective, maybe you can talk a little bit about the two things, right? So one, we think you've got some dollars, there's some articles out there that you might have got about $250 million from Florida in terms of extra Medicaid payments. can you talk a little bit about that? Was it recognized in the fourth quarter? Is it in the guidance for 2022 or because you have, maybe you haven't gotten them yet, so you didn't recognize it yet. So that's number one. And then number two, just in terms of your pricing assumption, in terms of revenue per admit, uh, is it fair to say then that it'd be versus the typical two to 3%, you're saying one, you're assuming maybe about 1% of that, uh, is kind of a headwind from government dollars that are going to be down materially. And then the other 1% is a little bit of, you know, half to 1% is maybe, you know, a little bit of, you know, payer mix deterioration. Is that a reasonable way to think about it?
Mark
Right. Yeah. So let me try to address those. Let me talk about Florida and the other supplemental programs that we have in the quarter. And I know there's been a lot of discussion. We are participating in the Florida DPP program. And in the fourth quarter, we did recognize a net benefit of approximately $130 million related to that program. We do expect to recognize a similar benefit in the latter half of 2022 as well. But I also want to talk about Texas for a moment. I think it's been reported that CMS has not yet approved the Medicaid directed payment program in Texas. That was to go into effect September 1st of 21. And as a result of this new program not being approved, we did not record any revenue anticipated with this aspect of the waiver program in the last four months of the year. So this equated to about $120 million reduction in our waiver revenue in the fourth quarter compared to what we had recognized in the three previous quarters. So it largely offset the impact of the Florida program in our consolidated results. We believe eventually the Texas program will be worked out, and we don't anticipate it being a headwind for 2022, but our guidance anticipates that we'll be able to recognize that annual historical level over time, even though it may take some time for the state of Texas and CMS to work that through. On the pricing side, you know, our revenue per emit at 1%. You're right, it's a little lower than maybe historically on there. When you adjust for the COVID, it does add about a point, so I think that's right. And then when you think about our outpatient revenue growth, as I mentioned, we expect to be in the mid to high single digits, and you blend that, I think it would look relatively consistent when you look at revenue per equivalent admission. So we think it's generally in the range of what our historical trends would indicate.
spk17
Okay, can I just ask a quick follow-up, Bill, on the Texas and Florida? So the way to think about them for 2022 is you're building in this extra 100 and let's say 30 million for Florida is in the 22 guidance. And then theoretically, you would also have a catch-up, right, from the fourth quarter or those last four months where there's an extra 130 million dollars So there's another $250 million of kind of extra dollars that are either out of period or probably may or may not continue from Florida and Texas in 2022. Is that the right way to think about it?
Mark
Well, Justin, I think in our guidance, we're anticipating an annual amount, a 12-month in our guidance. We're not anticipating a catch-up just given the uncertainty of how that may settle out. So we're going to have to wait to see how that develops. The state of Texas is contesting that. that federal program. We're hoping that we get some understanding of that soon. So our guidance really only reflects an annual amount, not necessarily a catch-up amount from this year. And so we'll just have to wait and see how that plays out.
Operator
Got it. Thanks, guys.
spk02
Thank you, Justin.
Operator
Our next question is from A.J. Rice with Credit Suisse. Your line is open.
A.J. Rice
Hi, everybody, and thanks. Best wishes, Mark. I won't say how long we've been interacting. But maybe I'll pivot and ask about you guys have talked about from time to time in the COVID crisis, some of the downstream ability to discharge has been challenging, home health, SNFs, whatever. And you've also talked about that maybe having some impact on your capital deployment priorities. Just give us your updated thoughts as you see Delta, Moderate, Omicron come co-surge. Are you seeing issues with being able to discharge patients in the timeframe you'd want? And any updated thoughts on having any of those areas as particular new or increased capital priorities?
Sam
Thank you, AJ.
Michael Cuff
One of the areas that we're focused on, and it's connected really to our labor agenda, it's connected to our overall business agenda for 2022, is managing capacity and throughput most effectively. So case management, length of stay management, discharge planning, post-acute and other settings is very important to our success. ER throughput is All of those elements are very important to our ability to manage capacity. And then clearly we have to execute on our labor agenda, and we have a robust labor agenda to respond to the issues that we face on the people side of our equation. And as it relates to the surges, discharge planning during the surges has been a little bit more difficult. It's been more difficult in the Omicron variant because the nursing home environment and even the home care environment has been suffering from employees who have been infected by the Omicron variant. And so that's created a little bit of a contraction, we think, in some markets with overall post-acute capacity. And that has delayed our ability to execute on our discharge planning process as we ordinarily would. As it pertains, AJ, to our capital planning, as you know, we did acquire the home care and hospice business unit from Brookdale. We have been in the process of integrating that business into our company. And the first part of this year has been about integration. We sold non-overlap components. to another home care company, and then we've been organizing ourselves around home care and hospitals inside of the markets where we overlap. And so, again, we're in the early stages of integration. We're looking for some significant strides on that front in 22. Additionally, we're making significant investments in rehab, as we've mentioned on these calls, in the past, particularly in Florida, but also in other components of our businesses. and we think that will enhance our ability to manage the post-acute discharge process a little bit more efficiently. We also have preferred networks that we've evolved with our bundle payment programs over the years with certain providers in post-acute. We will continue to leverage and build on those relationships, allowing us hopefully to maintain efficient discharge planning process. The last thing I would say on that front as well is our case management program is continuing to be advanced in our company. We are implementing technology. We are deploying certain shared services capabilities around utilization review and so forth. And we think those initiatives are going to yield benefits for us as it relates to capacity management. So a lot of components to this, AJ, Overall capital spending, however, to sum it all up here, is not materially changing from what we previously indicated. Okay, great. Thanks.
Sam
Yeah, thank you so much.
Operator
Our next question is from Pito Chickering with Deutsche Bank. Your line is open.
Bill
Hey, good morning, guys. Thanks for taking my questions. I want to echo everyone's comments. Mark, a big thank you. It's been a pleasure working with you over the years. And Frank, I look forward to working with you again in the future. So to test you guys, I'm going to ask a single sort of multi-part question here. So labor is obviously a big topic these days. So sort of the first question is, how should we model the cadence of earnings in 2022 versus the pre-COVID year? Number two, on 3.8% of revenue growth guidance, you're only guiding to 50 base points of margin compression despite these labor pressures. Can you give us any color on where, you know, salaries and benefits tracks in 22 versus 21 and any other color on supply and OPEX? And then finally, number three, what assumptions are you making on labor costs throughout the year? Do you have a moderating, same levels, any color you can give us there? Thank you.
Mark
This is Bill. We start with a quarterly case. We don't give specific guidance. But I think when you consider the discussion I had around the Texas waiver program, we think that will take some time to settle out, potentially even into the second half of the year. And then we think about labor, you know, with the current trends, probably more pressured in the first half of the year. We think we can continue to manage through those in the second half of the year. I think it's reasonable to expect that our growth will be weighted in the second half of the year. We expect that, you know, as we've seen the utilization of some of our premium labor, especially around contract labor, that we can ease that as we go through the balance of the year as hopefully we get out of a COVID surge environment, and that will provide some relief as we progress through the second half of 2022. On supplies and OpEx, our assumptions are really consistent with our trans. When I look at those two areas as a percentage of revenue, they stay pretty close in terms of the variability from period to period. So there's really no major tailwinds or headwinds that I would call out on those. I think our supply trends and our other operating trends would be consistent with, I think, what we've seen throughout most of this year.
Bill
Okay, great. And actually, a follow-up question on the premium labor. Can you quantify how much premium labor you guys saw in fourth quarter and what you're assuming in 2022? Thanks so much.
Mark
Well, I think we did obviously have to utilize higher contract labor. I think the impact was as much about the cost to procure that contract labor as it was the utilization. Our contract labor FTEs were up maybe, you know, 10% compared to where we ran in the first quarter. But the cost to procure that contract labor FTE was up, you know, significantly. So we believe that as the COVID surges begin to dissipate that the cost per contract contract labor will be able to manage through that and manage that down. So those are basically the numbers right now. Great. Thanks so much. Thanks, Beto.
Operator
Our next question is from Whit Mayo with SVB Learing. Your line is open.
spk07
Hey, thanks. Best wishes, Mark. Bill, my question is, when I look at the framework that you've offered up for 2022, I may be off a point or so here, but if COVID is budgeted to be 3% to 5% of your total admissions, it does seem to imply that non-COVID admissions grow maybe somewhere in the high single-digit range, but that could be roughly flat versus 2019. So I'm just trying to see if you can put into context the growth in non-COVID and how that's been trending and maybe any color around service lines just to help us bridge that increase and any views on maybe the first quarter could be helpful. Thanks.
Michael Cuff
All right. Thank you, Whit. If you look at COVID in discrete terms, you're probably not incorrect with some of your estimations, but I don't think we're viewing COVID completely discrete in a sense that some of those patients would still be entering the system regardless of COVID. And that was especially true in the fourth quarter as we looked at some of our COVID patients and such that they were coming in for different reasons. And then they were also COVID positive because many people didn't even know they had COVID. So I think you have to sort of look at it as a bit of a mixed bag there. That's how we're judging it as well. I do believe that there was deferred demand and it still showed itself in the quarter and will yield some recovery in the first part of 2022. I mean, literally we had surgeons who were closing practices, canceling cases because they themselves contracted the Omicron variant. So I think from that standpoint, there is, you know, the typical COVID impact on volumes in the quarter while we're experiencing a surge. But we believe, again, that strong job growth across our portfolio of markets, more people covered by the exchange, deferrals, some elective and transfer closures across our portfolio all bode well for our ability to recover volume in 2022. Again, as I mentioned to AJ, we have to manage capacity. We have to supply that capacity with labor. And we're working through all of those elements as we speak to put ourselves in the best position to receive that demand. But we're very excited about the prospects for growth across the company. As I mentioned in my comments, we're investing in that. We've announced, as I mentioned, eight new hospitals. recognize some of the overall growth that exists in these markets. We've had momentum. If you look at our market share at the end of 2019, it was north of 26 and a half. It ended with the most recent data that we get, which is about a year and a half later, right under 28%. So we gained share during COVID. We positioned our organization, we believe, with our ambulatory network better. And when we bump that up to what we're judging to be some demand that's been dislocated by the COVID surges, we feel like our guidance is reasonable.
Kevin
Okay, thanks a lot. All right, thanks, Will.
Operator
The next question is from Sarah James with Barclays. Your line is open.
Sarah James
Thank you, and I echo the heartfelt comments to Mark. How much of the wage inflation environment do you think of as a structural shift or a shift in how we think about the base wage range for nurses? And how does that impact your conversations with payers and how you think about CapEx or capital deployment mix?
Michael Cuff
Thank you, Sarah. Well, as Bill mentioned, The market has been significantly disrupted. The labor market, that is, has been significantly disrupted with COVID. What we see during COVID surges is more opportunities for our nurses and other people's nurses to go into a traveler and get a really outsized rate. We think as COVID surges moderate, that is going to moderate the overall labor market to some degree. We have advanced our wages for our employees. We've advanced some of our benefits. We've provided certain shift bonuses throughout the year, and that has yielded some increased rate of wage growth for our employee base. We think, however, moving into 2022, as we go through the moderation on the contract labor, we'll be able to absorb the wage trends that are built into our employee base over the course of 22 and land somewhere around 3 to 3.5% possibly on a composite basis for our cost per FTE. And that, we believe, is something that we can absorb in our guidance. As it relates to our payer contracts, yes, we are talking to them about inflationary pressures and how that will influence future contracting. At this particular point in time, our book of business for 2022 is pretty much accomplished and part of 23 is accomplished. But we're building in some flexibility to reflect the inflationary pressures that might exist. And we'll continue to work through those as we work through our contract portfolio with the different payers. But I think, in general, they understand the pressures that providers are facing on that front, and they have the unique ability to adjust their premiums on an annual basis in most instances. And that should line up with the need for us to get a fair cost increase related to inflation. All right, Sarah, thank you so much.
Operator
Our next question is from Scott Fidel with Stevens. Your line is open.
Scott Fidel
Hi, thanks, and we'll echo the thanks to Mark and best wishes to Frank. I had a question. I was interested to get a few more details on the eight hospitals that you've announced that you're going to plan to build an aggregate in Florida and in Texas. And I'm just specifically interested if you could talk about what the overall related CapEx would be for those facilities and the ROIC that you think you could generate on them. And then also, you know, maybe an aggregate sort of new beds that you'll think that you'll be able to add from those eight facilities and when in terms of timing those are expected to come online. Thanks.
Sam
All right, Scott. Thanks.
Michael Cuff
Well, I would submit that the eight projects that we've announced is not going to materially change our capital thinking over the next, you know, two to three years. We believe we can absorb most of that in... what will be a budget that's approximately what we're indicating for this year. The situation is this. Some of these markets are growing significantly. Austin, Texas, as everybody probably knows, is growing in a way that is creating opportunities for us, just like it's creating opportunities for others in that community. But with the growth in that market and with the occupancy that we currently run, In Austin, Texas, as an example, it presents a nice platform for us to expand into some of these growing areas and add to our network. Most of these hospitals will be primary and secondary care type hospitals with basic inpatient services and many outpatient services. And then to the extent that these patients need deeper, more acute care, we obviously have those capabilities in place. our different markets. We have the same situation in Florida with the exception of one hospital that we're building in Fort Myers, which is a new market for us. We're extending into that market because there's a need for more capacity and it's proximal to one of our West Florida markets in a way that we think we can create I think with respect to returns, we have a pattern, we believe, of producing very solid projects. It's reflected in our return on capital overall. We anticipate that these projects over time will yield the same kind of value that we typically generate with capital programs. So that's where we are with them. Again, most of them are going to be 50 to 75 beds starting out. They're not huge hospitals. They're complementary assets that over time will hopefully grow to more acute and more capable facilities with respect to service offerings. All right.
spk02
Thank you, Scott.
Operator
Our next question is from Gary Taylor with Cowan. Your line is open.
Gary Taylor
Hi, good morning. Mark, congrats. Not to make you feel old, but I think HCA had $2 billion of revenue in 1982 when you started, so you've come a long way.
Sam
That's right. I remember.
Gary Taylor
Thank you. One clarification and one question. I just want to clarify the Utah hospitals not yet in the guide, and then my – question just going back to labor. I know you've covered a lot on it. I appreciate it. But Bill, on the 3Q, you had talked about contract labor, overtime, shift differentials, and you had said 10% to 12% of FTEs were in those premium categories. And I think all three of those were included in sort of the premium categories. So I just wanted to get a sense sequentially if you have that figure, if there's a sense that that eased at all yet or we're still waiting to see that.
Mark
Yes, Bill. Two answers. Yes, Utah is not in our guidance. We're still in a regulatory review process. We've not included any of that in our guidance. Regarding the contract labor and premium labor trends, we did see some improvement as we went through the fourth quarter. I think the number's closer to 11% of our nursing hours were contract hours in the fourth quarter. So there is some slight improvement going forward. And, you know, as we think about my earlier commentary, you know, we think in the first half of 22 we'll continue to see that pressure. And over time, as the year goes on, as health code dissipates, we'll be able to manage that process down.
Operator
Thank you.
spk02
All right. Thanks, Gary.
Operator
Our next question is from Jamie Purse with Goldman Sachs. Your line is open.
Jamie Purse
Hey, good morning, guys. I just wanted to ask one clarification first on the COVID-DRG Herson sequestration for 2021, if you can give a breakdown of that $900 million, and same thing for 2022, the $150 million that you're planning for. And then my real question is just around, I think Whit was getting – to this question, but the implied non-COVID volume in 2022. You know, you're certainly not implying you get back to trendline, maybe back to 2019 levels, but really, what is the bottleneck to get back to trendline growth? Is it discharge capacity, labor capacity? You know, what are those bottlenecks that you would have to work through to see upside to non-COVID volumes?
Mark
Yeah, let me take the first part of that, the breakdown of the COVID support. It was roughly $180 million from the DRG add-ons. The sequestration delay was about $200 million for us in 2021. Then we had a little over $400 million of HRSA reimbursement and a little bit of technology add-on payments after that. Regarding in 2022, we know we have some visibility into the sequestration being phased in. That would say is roughly half of the $150 million we talked about and the rest being from the other programs.
Michael Cuff
I think on the capacity side of the equation, again, if you categorize how we're approaching making sure we have adequate capacity, and we have to execute on these categories in order to achieve that, First is staffing. We have to retain the staff we have, we have to recruit new staff, and we have to manage that obviously cost effectively. Again, we have a number of initiatives in place to deal with that. I'm encouraged by our hiring. We've advanced our recruiting agenda. We've got improvements in certain categories with turnover. Again, getting through COVID surges will be helpful to that. The second thing we're working on is what we're calling new models of care. We're exploring and experimenting with different approaches to staffing models that allow our nurses to be supported by different approaches, creating more capacity, if you will, for our nurse population. in a way that delivers the patient outcomes we want and recognizes some of the market issues. And then the final piece is what I had mentioned previously around throughput and capacity management. And again, case management's a piece of that. Telemedicine inside of our hospitals is a piece of that. Load balancing across all of our bed capacity market is a piece of that. So we have a lot of elements. Technology also factors into that and how we're using some new technology solutions to help us in throughput management. So those are the areas that we're focused on. And I've got confidence in our teams and our abilities to execute around these categories and deliver the capacity that we're going to need in order to take care of the demand that's going to be in the communities. All right. Thanks, Jeremy.
Operator
Our next question is from Jason Cazorla with Citi. Your line is open.
Jason Cazorla
Great. Hey, fellas. Thanks for taking my question. I guess just on the payer mix side, can you help flush out volume growth in the quarter by payer cohort and how you're thinking about 2022 in context of that two to three percent overall volume growth embedded in guidance? You know, you suggest the stability in payer mix for 22, but just wondering how you're thinking about the impact of any potential Medicaid re-verification activity, and especially the pickup in marketplace enrollment in your bigger states, I think, particularly in Texas. So any help there would be great. Thanks.
Mark
Yeah, I mean, in the quarter, we saw continued favorable payer mix. Our managed care book for the quarter was up about 2.6%, you know, compared to our overall emissions that became favorable. That was partly driven, if not mostly driven, by the health insurance exchange volume. We continue to see that we've talked about good enrollment going into that. As we go forward into 2022, as I mentioned in my comments, I think we're expecting that our CUNY and payer mix should continue to be positive trends. Maybe not at the same pace we've seen over this past several quarters, but we expect some continued positive growth on that. Relative to the Medicaid piece, we've seen some pluses and minuses of Medicaid. Medicaid growth is up a little higher than our average. In terms of expectations for next year, I think they would be mostly consistent with what our recent trends have been. I'm not so sure what else was tagged in on his question.
spk02
That was it, yeah.
Kevin
All right, thank you so much.
Operator
Our next question is from Brian Tanquillette with Jefferies. Your line is open. Hey, good morning, guys.
Brian Tanquillette
And Mark, thanks again for all the help over the years. I guess, Sam, my question, you know, in your prepared remarks, you talked about how you saw the migration of inpatient ortho to outpatient. So just wondering how you're thinking about strategizing around that and how that plays out going forward and maybe any color you can share on the difference in economics, maybe on an EBITDA basis, apples to apples for procedures, you know, inpatient versus outpatient on ortho.
Michael Cuff
So our total orthopedic volume, surgical volumes were up when you look at inpatient and outpatient in total. We have a physician alignment strategy with our orthopedic community that we think is yielding value, continue to iterate on that to respond to some of the the individual needs from one market to the other. The second piece of our strategy is around our outpatient elements and how we manage our surgical space in the hospitals for outpatient cases and then also in our ambulatory surgery centers where we have orthopedic partners. So we have a multi-pronged approach to orthopedics just like we do with most service lines and it involves our quality agenda, our service agenda, our facility agenda, and then our physicians. And so we have the same dynamic with orthopedics. You know, the reimbursement per case is obviously less in an outpatient environment than it is in an inpatient. But I think the important thing about HCA Healthcare is we have such a diversification of services And no one service provides a disproportionate amount of revenue or profits for the company. So when there's migration from one setting to the other, it doesn't necessarily change the overall equation for the company. And that's what we're seeing with orthopedics today. It's migrating. We've had other service lines over the years migrate from inpatient to outpatient and And we've been able to manage through that and actually create market share momentum around that transition. And we're believing that we have the right approach here with orthopedics as well.
Kevin
Thank you. Our next question is from Calvin Sternick with J.P. Morgan.
Operator
Your line is open.
spk09
Yeah, hey, good morning. I just wanted to circle back to some of the Medicaid comments you made, you know, specifically related to redeterminations. Just want to understand, you know, what's assumed in your guys' guidance with respect to the resumption of Medicaid redeterminations and, you know, whether or not you think that has a discernible impact on your numbers, particularly in the back half. Thanks.
Mark
Make it clear when you say redeterminations. We talked about the supplemental programs. Redeterminations. around eligibility. Yeah, I don't think there's any material assumptions in terms of changes of that into our expectations going forward. We haven't heard any discussion of that impact in our Medicaid volume projections going forward. So I would tell you that I think for next year it's built on our historical trends remaining pretty consistent.
Sam
All right. Thanks, Calvin. Chris, we've got time for two questions, please.
Operator
Okay. Our next question is from Joshua Ruskin with Nephron Research.
Joshua Ruskin
Your line is open. Great. Thanks for fitting me in, and congrats, Mark, and welcome, Frank, as well. On the labor front, I'm curious if you're seeing competition for clinical labor specifically, you know, physicians, nurses, et cetera, and if that's mostly coming from, you know, other hospitals, competing hospitals, or maybe staffing situations, or Are there trends where individuals, the clinical labor is going to other areas, other sites, or maybe even leaving health care, because we continue to see that in media reports? And then maybe just a comment on Galen and the impact that that's having, you know, and how that may be a competitive advantage for HCA.
Michael Cuff
Well, I think all of the above on labor. I mean, there's clearly competition for labor, not just in clinical labor, but non-clinical labor, too. The service side of our... agenda. We have competitive dynamics on that labor front as well. We're no different than any other industry when it comes to that. I think, again, we have advanced our recruitment very significantly. We're recruiting significant numbers of nurses. We have retention efforts that I think are going to pay off. The care transportation that I mentioned earlier and capacity management, all that's connected to a staffing solution for our company. And we're competing very aggressively in this space, just like we compete for physicians, just like we compete for patients and so forth. So I'm confident in our competitive abilities on this particular agenda. Galen is off to a great start. We acquired it and we're limited to when we could start our expansions. We started our expansions this past year. I think we have 12 new schools in the pipeline. Maybe six or eight of them have actually opened. One in Austin and one in Nashville were both the fastest ramp up in new enrollment in the history of Galen, their CEO told me. So we're very excited about the prospects. It will take us time to graduate these nurses, but we expect to have you know, 12 to 18 new schools over the next two to three years and that should yield a number of new students for us. We will integrate those students into our facilities in ways that hopefully secure an employment opportunity for them in an HCA facility when they graduate. We anticipate tripling the number of graduates over what they currently produce by 2026, which yield a reasonable growth in number of nurses in the communities that, again, hopefully we can retain. into our facilities. We believe our faculty will be supported by HCA, nursing leadership, and then the externs programs that we'll use for students in the Galen School will be integrated into HCA procedures, systems, and so forth. And we do think that creates some advantage in securing these graduates into our facilities. All right, thank you, Josh.
Operator
Our final question is from Ben Hendricks with RBC Capital Markets. Your line is open.
Ben Hendricks
Hey, thanks, guys, for squeezing me in at the end, and congratulations to both Mark and Frank. I think most of my questions have been answered, and you've touched on this, but just kind of get back to your inpatient care delivery efforts and then the length of stay management. This is all a consistent theme we've heard from your competitors. Certainly, Tennant has talked about this in community as well. But just wanted to get a little bit more color on what you think are your key differentiators, whether it be your scale, your approach, and kind of what might give HCA the competitive advantage in that endeavor. And then follow on to that, kind of what inning are we in? How much room to run do we have on getting efficiency out of specifically the care delivery? All right. Thanks, Ben.
Michael Cuff
I don't know what the other companies are necessarily saying about this particular agenda. I think what we're trying to do is make sure we're using technology. We have training and visibility into the process that make a difference in case management. And then we're ultimately using our capacity broadly across the markets to support better throughput and overall capacity management. And then, as I mentioned, we've advanced our capabilities in post-acute with our own acquisitions and development, as well as relationships with others. And I think the combination of all of those elements create an opportunity for us to gain more efficiencies through our case management programs overall. And we think also that will help us with our receivables and our management of denials and so forth with the payers and there's some yield on that front as well. So we're pretty excited about the developments in this area. How much more advantaged we are than others, I can't really speak to that. All right, Chris.
Operator
That concludes the question and answer session. I'll turn the call over to Mr. Hazen for any closing remarks.
Michael Cuff
Yeah, well, thank you again for participating on our call. And I wanted to take this moment to thank Mark for his 39 years of service. He and I both have worked 39 years with the company. I'm not sure why he's retiring. But nonetheless, he has had a wonderful career and represented our company incredibly well with our shareholders and others. And I want to thank him for that. And, again, welcome, Frank, to the team. Frank's going to do a wonderful job as well. So, Mark, congratulations. Thank you. Appreciate it.
Sam
Well, I wanted to say a few things, too. And finishing up our final earnings call, I wanted to thank Sam and Bill and all the others I've known and worked alongside these past 39-plus years. You know, I've truly enjoyed working with everyone here at HCA and all of you listening on the call today, too. I also want to thank Dr. Fritz for his vision in creating HCA. and Vic Campbell for his years of mentoring and friendship to me over the past decades. Frank and I will be here to answer any further questions you might have following this call, so feel free to give us a shout this afternoon or later in the week. Thank you so much.
Operator
Ladies and gentlemen, this concludes today's conference call. Thank you for participating, and you may now disconnect.
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