Tenet Healthcare Corporation

Good morning. Welcome to Tenant Healthcare's third quarter 2022 earnings conference call. After the speaker remarks, there will be a question and answer session for industry analysts. If you'd like to be placed into question queue, please press star one on your telephone keypad. Tenant respectfully asks that analysts limit themselves to one question each. I will now turn the call over to your host, Mr. Will McDowell, Vice President, Investor Relations. Mr. McDowell, you may begin.

Good morning, everyone, and thank you for joining today's call. I am Will McDowell, Vice President of Investor Relations. We're pleased to have you join us for a discussion of Tenet's third quarter 2022 results, as well as a discussion of our financial outlook. Tenet Senior Management participating in today's call will be Dr. Som Satoria, Chief Executive Officer, and Dan Kinselemi, Executive Vice President and Chief Financial Officer. Our webcast this morning includes a slide presentation, which has been posted to the Investor Relations section of our website, tenanthealth.com. Listeners to this call are advised that certain statements made during our discussion today are forward-looking and represent management's expectations based on currently available information. Actual results and plans could differ materially. Tenant is under no obligation to update any forward-looking statements based on subsequent information. Investors should take note of the cautionary statement slide included in today's presentation as well as the risk factors discussed in our most recent Form 10-K and other filings with the Securities and Exchange Commission. With that, I'll turn the call over to Sam.

Thank you, Will, and good morning, everyone. I'd like to start by taking a moment to remember Ron Rittenmeyer, our former executive chairman, who recently passed away. Ron had an unwavering commitment to Tenet for which he will always be remembered. This included ensuring a seamless transition in management, which was substantially completed late last year. Ron was a dear friend and colleague to many, and our thoughts remain with his family. Let's turn to the quarter. Throughout the third quarter, we continued to deliver high-quality care for our patients and value for our stakeholders. We delivered favorable results with enterprise net operating revenues of $4.8 billion and consolidated adjusted EBITDA of $841 million in the quarter. Our operators effectively navigated a significant COVID surge impacting staff availability during the summer, continued our recovery from the cyber attack, and supported operations throughout Hurricane Ian. Despite these challenges, we exit Q3 with a positive trajectory for the remainder of the year. USPI demonstrated continued EBITDA growth and strong free cash flow generation in the quarter. the segment delivered EBITDA growth of 16.4% over prior year. We are very pleased with the expanded portfolio we've built, but must acknowledge that we are behind our original 2022 plan for USPI. Throughout the first half of the year, we were confronted with some of the challenges impacting the segment, but we also had periods where performance met our high expectations early in 2022. In the third quarter, multiple things came together And when performance did not meet our increasing expectations sequentially through this year, we decided now is the time to reduce our guidance in the segment. It is important to unpack this because the impact is mostly due to shorter-term disruption rather than any change in our future outlook for the segment. We are also not seeing evidence of recession-related, in quotes, patient demand changes. we continue to see ongoing recovery in elective diagnostic procedures such as in GI and anticipate seasonal growth in Q4 like in previous years. With that summary, let's go through the unpacking in some detail together. In Q3, the segment generated approximately 40% EBITDA margins and maintained 100% of pre-pandemic volumes. USPI did not face a significant trail off in business, nor a shock that caused the business to fall backwards from its trajectory this year. In Q4, we are still targeting sequential seasonal earnings improvement above Q3 of approximately $86 million at the midpoint, from $319 million to $405 million. This is a very attractive business and deserving of the investments we make in it. Now let's turn to why the business has not met expectations in Q3. First and more recently, Hurricane Ian had a modest adverse impact on 60 USPI centers in Florida and South Carolina. While the majority of cases have been rescheduled over the next few months, there are still four centers that have not resumed fully normal operations. Second, case cancellations spiked in July to nearly 20% and remained high throughout the summer COVID spike. The lingering impact on COVID has impacted staff and physician availability, as well as demand from doctors' offices not running at full throughput. Stepping back, if you recall, our original assumptions for USPI in 2022, as we have indicated before, included minimal impact of COVID in the growth we expected from the segment this year. Despite this, as I noted, USPI delivered surgical volumes consistent with 2019 pre-pandemic levels. Recognizing the shortfall to expectations, each center is currently working through 2023 plans for further growth with no change in the mindset about a strong ongoing recovery from COVID. we are not changing our assumption that our ASCs should target 4% to 6% organic year-over-year growth in EBITDA over the long term. Third, USPI has also seen the adverse impact of global supply chain issues. Let me explain. New center de novo developments, which is a rapidly growing and very attractive part of our portfolio expansion strategy, have been delayed or slow to ramp up. This includes many of the second SCD transaction centers which were either still in development and or yet to open. To make this tangible, we are dealing with delayed shipments of everything from air handlers to electric switchboards to OR infrastructure to get these centers open. Remember, each center is a well-syndicated physician partnership wanting to fully ramp up their surgical cases. I want to be clear. We remain confident in the future performance of these centers when they open, and a special development team is coordinating with the tenant supply chain leaders to alleviate bottlenecks as quickly as possible. As an added point, the exclusive development agreement with SCD's principals to syndicate new partnerships on the next 50 centers is still on track in year one. Fourth and finally, The pace of USPI's consolidating biops in the SCD centers after success in Q1 and Q2 has slowed in Q3. We've worked with the physicians in these centers and there is further opportunity for some of the centers to mature before completing the biops and we can deliver our added synergies. We will not force these unnaturally as the relationship with these physicians is foundational to our ongoing success. I want to be clear here as well. These centers are performing well. Their earnings are consistent in a range of our expectations, and they are continuing to ramp up. As we are a substantial minority owner in these centers, we do participate in this strong performance, but not yet at the consolidating equity ownership levels we originally anticipated. Service line improvement continues to be important to our earnings growth at USPI. Similar to what we have done in a data-driven way in the hospital segment, we continue to focus our business in the ASCs towards higher acuity service lines. For example, the continued growth in our orthopedic and spine business at the end of Q3 now represents 20% of our total volume. Our focus is on net revenue intensity and margin expansion more so than only case volumes in some of these markets. Let me give you one example to illustrate the point. At an ASC facility in Tennessee, we have seen a 25 percent decline in volume on a year-to-date basis, but we have had an overall increase of 46 percent in net revenue per case and growth in the EBITDA of 10 percent because we replaced high-volume, low-acuity cases with high-acuity orthopedic cases. I hope the transparency about the segment is helpful and gives you a basis for the strength of our conviction in USPI. Turning to inorganic growth at USPI, our M&A pipeline is very strong. We remain committed to Tenet's portfolio diversification strategy into ambulatory surgery with a baseline intention of $250 million of M&A and de novo investments each year. We completed our acquisition of 22 United Urology Group centers in the third quarter, which adds well-established and new ASCs in key markets like Arizona, Colorado, and Maryland. In Q3, we added 32 centers to the portfolio across 10 states and advanced de novo development for 15 additional centers currently under construction. Adding centers with very attractive margins and post-synergy multiples remains the best use of our cash for investments to enhance tenants' free cash flow. In total this year, we have added 45 centers, and this 2022 vintage has an estimated average year two multiple below five times. We are optimistic about USPI's performance in the fourth quarter and into the coming year. As I indicated, our assumptions this year about COVID primarily impacting only our hospital segment and generally not our USPI segment just didn't play out that way. The team is focused on organic growth, increase in higher acuity services, and M&A. Like in previous years, we are starting to see the seasonal demand for surgical care increase in Q4 and are adjusting our operations to accommodate that demand. Our track record in this business is very strong and very long, and our conviction behind the strategy is unchanged by a year of short-term challenges. Let's turn to our hospital segment, which generated $432 million in adjusted EBITDA in a challenging environment. In July, we had an increase in COVID admissions and procedure cancellations. But more importantly, during July with the Omicron surge, nearly 10% of our clinical staff in the hospitals were out at some point in the month due to COVID. These dynamics led to compressed patient volumes in July, and for us, increased our procurement of contract labor staff, which impacted the quarter. Our management of contract labor utilization has been very strong during the last two years. But in Q3, it rose to 7.4% of consolidated SWB from 6.2% in Q2. However, our teams immediately made data-driven labor productivity improvements and clinically appropriate length of stay reductions, which kept our total SWB as a percent of revenue in line with pre-pandemic levels and importantly demonstrated sequential reductions in the months of the quarter, such that we stood at 42.6% of net revenue in September. The point being operating discipline through the challenges we face is a continued strong point of our management approach. Our operators adapted quickly to the volume challenge from July, and hospital patient volumes improved sequentially during the quarter. We exited September with adjusted admissions nearly 6% higher than the prior year. Long-term fundamentals in our workforce are as important as our short-term management strategies. We have also applied a data-driven and streamlined approach to staff recruitment and retention and we welcomed over 2,000 additional nurses, many of them new graduates, to our care teams in the third quarter alone, which will benefit us over the coming quarter and year. We remain focused on enhancing high acuity services across our hospital portfolio, and our year-to-date case mix index has grown at a remarkable 4% CAGR since pre-pandemic in 2019. This is the result of continued clinical program development and capital deployment in cardiovascular, neurosciences, general surgery, neonatal care, and trauma. To share just a few examples, we added cath and EP lab capacity in Palm Beach, introduced the latest cardiac valve technology in Phoenix, expanded our robotics program in San Antonio, and began significant NICU enhancements in El Paso. Additionally, we opened the Piedmont Medical Center Fort Mill in South Carolina in September. It's off to a great start. Our dedicated team designed, built, and staffed the 100-bed state-of-the-art facility amidst COVID on time and on budget. The hospital provided emergency procedural and women's care for over 1,000 patients in its first few weeks. This is a great example of our commitment to providing high-quality specialty care closer to home in growing communities. Turning to Conifer, Conifer continues to demonstrate top line growth. Conifer delivered 6% revenue growth, including third party customer growth of almost 10%, with a strong 27% margin in the quarter. We continue to maximize opportunities through automation and offshoring to improve the effectiveness and efficiency of Conifer's services. We remain pleased with Conifer's strong performance on cash collections, coding quality, and other key metrics for our clients. Conifer's track record for performance, coupled with the reinvestment in commercial efforts, is gaining traction in the marketplace. For Tenet, Conifer's cash performance enhanced our liquidity by over $100 million compared to our target for the quarter. Our sales pipeline is up over 85% from prior year as our investments in commercial capabilities mature. As an example, Conifer recently won a competitive new five-year contract provide physician revenue cycle services to the sinai medical group in chicago our physician revenue cycle services help entities address the complexities providers are facing with payment models expanded network coverage and other regulatory changes based on our enterprise performance year to date and the realities of the challenges we face in the second half of this year we are now guiding to a full year 2022 adjusted ebitda guidance range of 3.375 to 3.475 billion. Quarter after quarter, each of our businesses has demonstrated discipline management and the ability to navigate unforeseen challenges. I'm confident in our team to continue to deliver strong results. Our consistent operating performance and deleveraging over the last few years has led to an increase in free cash flow generation. This has enabled us to deploy capital strategically to strengthen our operations and grow our ambulatory business. As we have discussed before and now, our board has authorized a share repurchase program of up to $1 billion. Our ability to generate free cash flow is an underappreciated part of our story, and we see our current valuation as compelling. We are pleased that our strong free cash flow enables us to efficiently return capital to shareholders while maintaining our commitment to grow the ambulatory business and further deleverage the balance sheet. And with that, Dan will provide us more details on our financial results.

Thanks, Simon. Good morning, everyone. Let's start on slide three. Given our improved free cash flow generation and the significant reduction in our leverage over the past several years and our belief there is future upside in our equity value, we announced a $1 billion share repurchase program that we'll start executing on. Our free cash flow provides us with the capital flexibility to balance share repurchases with investments to grow the business and debt retirement. I'll discuss capital deployment in more detail in a few minutes. As Saul mentioned, our financial results in the third quarter were impacted by significant COVID-related challenges, including the continuing inflationary wage and labor availability pressure providers across the country are facing. In the quarter, we generated a consolidated adjusted EBITDA of $841 million. The quarter got off to a slow start due to the impact COVID had on our patient volumes and staff availability. However, our volumes and labor trends strengthened considerably throughout the quarter. Our results were supported by continued high patient acuity and effective cost control. Our operators did a good job responding to the labor challenges as our consolidated SWMB costs as a percentage of revenue were only 60 basis points higher than the second quarter of this year, despite more difficult labor pressures. There were two items that were not included in our guidance which helped earnings in the quarter. First, we recognized $54 million of grant income. As a reminder, we are able to recognize grant income as a result of lost revenues and incremental costs due to COVID. And the second item is a $45 million gain on the sale of a large portion of our interest in certain assets of the Health Trust GPO we have an affiliation with. Now I'd like to highlight a few key items for each of our segments, beginning with USPI. which continues to deliver strong results, although not up to our high expectations. USPI's adjusted EBITDA grew 16% compared to last year, and its margin continues to be very strong at approximately 40%. USPI surgical case volumes were 100% of 2019 pre-pandemic levels and flat compared to Q3 last year. As Sam mentioned, USPI results have also been impacted by COVID-related challenges. However, we continue to deliver overall results that are strong in terms of margins and cash flows. Turning to our acute care hospital business, our labor management continues to be effective despite the cost pressures, especially contract nurse staffing costs that are temporary. On a consolidated basis, contract labor costs were approximately 7.4% of consolidated SWMB in the quarter, which was up from 6.2% in the second quarter and 6.8% in the first quarter. COVID-related factors and the impact of the availability of our staff created pressure on our hospital patient volumes, contributing to a 0.7% decline in adjusted admissions. However, just admissions did increase 3.4% sequentially from the second quarter. Also, hospital patient volume strengthened significantly throughout the quarter. Our case mix index and revenue yield remain strong as we continue our strategic focus on investment in higher acuity, higher margin service lines. Our year-to-date case mix index has grown at a 4% CAGR since prior to the pandemic in 2019. Let's now turn to Conifer, which delivered a solid quarter. Conifer produced revenue growth of 6% over last year, and importantly, revenue from external clients grew nearly 10%. Conifer generated adjusted EBITDA of $90 million, representing growth of 6% over third quarter last year, and continued to produce a strong EBITDA margin of 27%. Let me now turn to our outlook for the rest of this year. We have tightened the range for the year and reduced the midpoint $50 million to $3,425,000,000. At the segment level, we have increased the outlook for adjusted EBITDA for the hospital segment by $25 million at the midpoint in the range, and we reduced the EBITDA outlook for USPI by $75 million, reflecting the various impacts that Psalm previously discussed. I do want to mention that our Q4 guidance does not assume any insurance proceeds associated with a cyber attack. Based on our year-to-date results, we have also provided various updated guidance assumptions in our press release, including volume assumptions and a narrowing of certain ranges given we're heading into the last quarter of the year. Before we turn to cash flows and liquidity, let's turn to slide seven. I'd like to spend a minute to provide some context for the jumping off point for our 2023 EBITDA outlook. I want to call out the following items that will impact the comparison of our 2022 results to 2023 when we issue our guidance next year. First, $154 million of grant income recognized so far this year as a result of lost revenues related to the pandemic. Second, an unfavorable impact of about $100 million this year from the cybersecurity attack. Next, a $69 million gain this year from the sale of medical office buildings in the first and the $45 million gain from the sale of our interest in GPO assets that I mentioned earlier. Next, $30 million of Texas Medicaid supplemental funding revenue related to 2021 that we recognized earlier this year when the program was approved. Additionally, the full-year impact next year as a result of Medicare sequestration is expected to be a headwind of about $40 million And finally, the unfavorable impact on Medicare-related outpatient revenue from the rate adjustment in 2023 associated with the 340B issue is expected to be approximately $40 million. However, from a fundamental perspective, we anticipate positive tailwinds in 2023, including the possible moderation in the rate and utilization contract labor, Further recovery from the pandemic, which may drive increased volume levels. Continuing investments in hospital higher acuity service lines. Cost efficiencies that we anticipate executing on, including the transition of additional roles to our global business center in Manila. Our new Fort Mill Hospital near Charlotte and further improvement of our St. Vincent Hospital post-strike. USPI organic growth, additional USPI synergies from the SCD transactions, and other USPI-related M&A activity. Since we are currently in the midst of our 2023 business planning process, it's premature to provide any specific numbers on those items, so we will provide our full-year 2023 guidance on our earnings call in February. Moving to slide eight, let's review our cash flow, balance sheet, and capital structure. As of the end of the quarter, we had approximately $1.2 billion of cash on hand and no borrowings outstanding under our $1.5 billion revolver. We generated $555 million of free cash flow in the quarter before the repayment of Medicare advances that we received in 2020. All of these advances have now been repaid. Year-to-date free cash flow before the repayment of the advances is almost $1.1 billion. As a result of our continued growth and focus on deleveraging, our September 30th leverage ratio was 3.9 times EBITDA compared to 4.1 times at the end of last year. As a reminder, we have no significant debt maturities until July 2024 and have approximately $2 billion of secured debt borrowing capacity available, if needed. We have strengthened our balance sheet over the past several years and retired or pushed out debt maturities, which provides us ample flexibility to support our growth initiatives. Turning to our cash flows outlook for 2022, from a cash flow perspective, we continue to target another strong year of free cash flow generation of approximately $1.4 billion at the midpoint of our guidance, excluding the repayment of Medicare advances and deferred payroll taxes. Our free cash flow generation has improved substantially over the past several years, and we expect to continue to drive strong cash flows while executing on our growth plans. As we have previously mentioned, these cash flows provide us with significant financial flexibility to effectively deploy capital for the benefit of our shareholders. As we noted in the earnings release, our Board has authorized a $1 billion share repurchase program. The authorization reinforces the confidence we have in our long-term growth plans and the underlying cash flow generation of our businesses and the belief in the upside in our equity value. As a reminder, our capital deployment priorities have not changed. First, we plan to continue allocating approximately $250 million of capital annually to grow our USVI Surgery Center business. Next, to enhance our hospital growth opportunities, including the continued focus on higher acuity service offerings, Third, evaluate further opportunities to retire debt. And finally, share repurchases, depending on market conditions and other investment opportunities. And with that, we're ready to begin the Q&A. Operator?

Thank you. And I'll be conducting a question and answer session. If you'd like to be placed into question queue, please press star 1 on your telephone keypad. As a reminder, tenant respectfully asks that analysts limit themselves to one question each. That's one question each, and it's star one to be placed into question queue. Our first question is coming from John Ransom from Raymond James. Your line is now live.

Hey, good morning.

Just as we think about the hospital bridge from, say, second half of 22 to 23,

um dan do you have any like quantitative puts and takes um to think about that at this early stage thanks yeah john stan um you know as i sort of outlined in in my remarks um when we think about next year uh we you know we called out certain items that um occurred in um 2022 uh as well as items that will um that come into play next year, including, you know, full-year sequestration as well as, you know, the 340B issue. You know, I went through the various positive tailwinds that we do anticipate next year. We're in the midst of our business planning process, so we're not ready. We think it's premature at this point to put specific numbers out there for 2023. But again, the possible moderation in contract labor, further recovery from COVID, which may drive increased volume levels, and we're going to continue to allocate capital in our hospital, more complex service offerings, cost efficiencies. We've demonstrated a good job over the past several years executing on our Cost actions, there's more opportunities to transition additional roles to our center in Manila. And we have the new hospital in Fort Mill that just came online, and we continue to expect that hospital. It's in a great market, and we expect it to continue to evolve and grow from its initial start and drive incremental EBITDA next year, as well as our St. Vincent Hospital. Post the strike and the hospital, the performance has been improving throughout the year, and we expect that to continue into next year. And as we also mentioned, there's anticipated additional synergies related to the SCD transactions that will continue to grow as we move through next year as well. You know, the other thing is, you know, the M&A activity that USPI will execute on, the pipeline is robust. I'm sure we'll get into some questions on that with Brett and Sam. But, you know, we feel very good about the pipeline, and we feel very good about the type of value that we can bring to the table in those type of transactions. Okay, thanks.

Thank you. Next question is coming from Stephen Baxter from Wells Fargo. Your line is now live.

Yeah, hi. Thank you. I was hoping you could just expand a little on your expectations for USPI and Q4. You know, normal seasonality is a pretty significant sequential increase. Can you just confirm that you feel like you're seeing what you need to see exiting the quarter and in the early part of October to have confidence in that? And then broadly, some of the capacity constraints you've talked about, just confirm that you don't see that as a rate-limiting factor to achieving that normal seasonality. Thank you.

Hey, Steven. This is Brett. Yeah, so if you think about the midpoint of the range, that assumes 2.8% volume improvement in Q4. Year-to-date, we're at 2.5%, and as you noted, we do expect to see some some significant, not significant, but a nice surge in Q4 as we typically do. And we've also been kind of hovering around 100% of 2019 volumes all year. The 2.8% implies 101% of 2019 volumes. So we feel good about being able to get to that in Q4. And to your point, we are starting to see the signs of some improvement in case volumes as we entered into October, heading out of the second half of October.

Thank you. Our next question is coming from Justin Lake from Wolf Research. Your line is now live.

Thanks. Good morning. Just wanted to talk about inflation. One of your peers brought it up as a pretty significant uncertainty going into 2023. Anything you can point out to us in terms of what you're seeing, for instance, on supply, inflation, some of the other factors besides labor. And then on labor, you talked about contract labor being a benefit to the year. Can you talk a little bit about what your typical salary, wage, and benefit per adjusted admission trends are within your normal kind of algorithm for growth? I think one of your peers says 2% to 3% typically. And do you think contract labor, I know that's going to be a tailwind next year, Do you think it's big enough tailwind to offset labor inflation being a little more heated on the permanent side? Basically asking, do you think labor is going to be a tailwind overall when you layer in that contract leverage? Thanks.

Yeah, Justin, it's Sam. So let me start with those in sequence. The first part of the question related to inflation in supplies, infrastructure, et cetera. And, you know, look, we have faced those, but we have also since the beginning of the pandemic organized ourselves to consolidate vendors and at the same time find offsets in our purchase services and improvements in our supply contracting efforts on, especially on many of the kind of physician preference items that are consistent with our own high acuity based strategy. And obviously on commodities, we maintain a high degree of compliance with respect to purchasing through our GPO, which gives us additional benefits. And that's across the hospitals, the physician business and USPI from that standpoint. So there's no question about the fact that they're is an inflationary effect in those areas. But, you know, we've been working actively to mitigate that impact over time. The second part of your question relates to contract labor and base wages. And I'll focus, I think you were focused primarily on the hospital segment. So there's a few things there. You know, our nurse hiring that I mentioned is very important because it does, over time, change with the relationships that we've built in our communities with the nursing schools, change the mix of nurses and the overall wage mix of nurses as we bring new grads into the environment. And that's just not for nursing. It's for all, you know, all frontline staff. The second thing from that standpoint is that while it's not complete, You know, our approach to making wage adjustments, whether through our highly predictable at this point union contracts or in our other markets, has largely been factored in to our approach in 2022 going into 2023. So we're not anticipating a large number of much more significant base wage adjustments in our workforce outside of the norm. And so I would be very comfortable and consistent with the kind of numbers that you described. Look, on contract labor, this is obviously an area where it's highlighted in Q3, but our contract labor performance as a percentage of our SW&B has been significantly below what I think we have seen broadly in the industry. And it's been because we've had a very deliberate strategy of being thoughtful about where the marginal revenue would overcome the cost structure in our hospital facilities in order to manage our margins appropriately through this kind of staffing crisis. And we're going to continue to do that. You know, we have made assumptions going into Q4 that we will moderate on contract labor. The fact is that contract labor rates have not come down this year the way we anticipated back in our February guide. There's no way to escape that in terms of the labor rates. But we've tried to offset it, as I indicated, with strong productivity management and length of stay management in order to mitigate our use of contract labor. And we feel very good about our disciplined use of contract labor despite the increase in Q3. and the ability to get control of that going forward.

Thank you. Our next question is coming in from Whit Mayo from SVB Securities. Your line is now live.

Hey, thanks. Good morning. Maybe on USPI for a second, I think you guys called out a 20% spike in the cancellation rate. Can you just remind us what a normal cancellation rate is within the quarter and maybe what the impact was specifically on the case growth from those cancellations and also how much has been rescheduled and maybe just refresh us on the physician recruiting efforts and how you're tracking this year. Thanks.

Hey, Whit. This is Brett. Yeah, to answer your first question, so normal Normal cancellation rate for us is around 15%, 15 plus percent. So to see a cancellation rate at 20%, that's a pretty significant increase. And as you know, the cancellation rates, you know, during COVID have been anywhere from 16% to 20%. So actually 20 plus percent when you go back to 2020. So to see it at that level was pretty significant for us. Fortunately, you know, it came down sequentially month over month. As it relates to your question, I think you're kind of getting to, you know, where are we seeing volumes headed kind of going into the future and also what impacted volumes in Q3. So if you think about Q3 2021 on the same store basis, we saw volume increase of 6.8%. So it was a pretty difficult comp. In addition, as Sam alluded to, we did feel the lingering effects of COVID on staffing and physician availability and the cancellation rates that you referred to, as well as obviously the impact on our ASCs from Hurricane Ian. And just from Hurricane Ian, we saw probably anywhere from 2,300 to 2,500 cases that were lost. In September, fortunately, we've rescheduled a large majority of those cases in Q4. Also, getting to your point around physicians, I think in our conversations with physicians, the story for their offices is similar to ours as it relates to practice volumes being right around pre-COVID levels and the expectation or the exception, I would say, to that is ortho and GI. specialties that are slightly outpacing 2019 volume levels. But I would say most are optimistic. Most of the physicians are optimistic that once we get past the trailing impacts of COVID, then we'll see more of a recovery in their offices, which will obviously translate into surgical volume over time. All said, we do believe that we'll get back to normal growth rates as the physician offices recover. And as we continue to build out, to your point, our professional sales force, which we have been doing, and that professional sales force continue to collaborate with our operators to develop and execute very center-specific sales plans. And, of course, as we implement new higher acuity service lines across the portfolio, as Sam mentioned, that's a significant part of our growth story. as it relates to improving not only our acuity, but also our volume trends. So we've implemented 70 new service lines so far, 70 plus new service lines so far this year, and we have another 150 in the pipeline that we'll implement in Q4 and in 2023.

Thank you. Next question is coming from Peter Chickering from Deutsche Bank. Your line is now live.

Hey, good morning, guys. Thanks for taking my questions. I know you're not giving 2023 guidance, but there's a lot of noise, obviously, in 3Q and 4Q within the USPI segment. So as you think about 2023, is anything changed with the USPI growth algorithms? You said that the pipeline remains strong and believe that ASGs should sort of keep growing in the 46% range. So if history is a guide, this would be sort of 10% M&A plus 5% organic. You look at your guidance, that would apply at 980 of EBITDA less NCI. Is that how we should still be thinking about it or is there any change there? Thanks so much.

Hey, Peter. It's Sam. Good morning. As we mentioned, we still believe strongly in our ability to drive organic growth as well as the ability to execute on M&A, whether it's straight M&A or de novo development. And in terms of specifically for next year, as I mentioned, it's premature for us to put numbers out there at this point. But we have not changed at all our belief in the growth opportunities for USVI. It's a great business, great margins. great cash flow generation. And we believe we have competitive advantages when we engage in M&A when there's a competitive process based on the value that we can bring to the table. So we do believe the pipeline is robust. And so it gives us a lot of optimism as we think about 2023 and beyond. Certainly, the results this year for USPI aren't necessarily at the level that we assumed at the beginning of the year and through the second quarter. COVID certainly has had a much more significant impact on USPI than we anticipated and some went through the other various points in terms of the performance, but the results are still strong. They're just not up to the level that we expected.

Okay, just to follow up on the organic side, I think Saul mentioned the scripts for 46% growth. At this point, you're still uncomfortable that that's the right growth rate for 23%.

As I mentioned, when we get, you know, on our February call, Peter, we'll provide specific, you know, volume assumptions, you know, next year for USBI.

Great. Thanks so much.

Thank you. Next question is coming from AJ Rice from Credit Suisse. Your line is now live.

Hi, everybody. Just to drill down a little further on the Q3 results, I think in the prepared remarks, you're saying, Tom, that July was where you saw a lot of this hit on the quarantine clinicians, I guess, that drove you to take on these travelers. temp staff, a lot of those assignments are 12 weeks. So I'm wondering, by the end of the quarter, did you have excess travel nurse supply that you really didn't need? And did that just basically roll off? And how much of a tailwind would that be for the fourth quarter? And then also related to this, on USPI, I know you're also calling the quarantine issue as the main issue. I think last year with Delta, some procedures that were being traditionally done on inpatient got pushed to outpatient because people didn't want to get the surgery in a facility that was filled with COVID patients. I'm wondering, have you looked at how much your flat year-to-year trend in USPI was driven by the fact that maybe last year it was somewhat elevated and this year it's just more normal as inpatient seems to be showing some recovery on the surgery side? Maybe just see if you can comment on those.

Yeah. AJ, so let me take the hospital side first. On the contract labor question, you're right, that as we saw that effect through July in our staff, in the hospital business, we did end up procuring more contract labor to cover that. And you're right about, you know, these are generally 12-week cycles. So, you know, we're kind of hitting the end of those cycles right now, and that's why we, you know, we're going through the process of, of moderating, uh, what we had procured, uh, from that standpoint. I mean, just to dimensionalize this, that, that rate of our staff in particular in July being out, because we keep a careful count of this, um, is three to four times what we see when there's not, you know, COVID impacting the staff. Um, so it was for us, it was material and, um, And I'm sure there's variance state to state of what happens there, but it did cause us, as I indicated, to increase our procurement of contract staff in order to maintain the service lines that we prioritize being open. And again, I'd reiterate, we've been very disciplined about where we place contract labor. So the fact that we increased our utilization of contract labor, you can rest assured was based upon a belief that we wanted the volume that we were seeing. As we go into Q4, just like in the USPI business, the hospital business also has some degree of seasonality to it for a variety of reasons. And so we would expect our use of contract labor to be better matched, perhaps, with the type of demand that we would see there. On the USPI side, and I'll pass to Owen here in a second with respect to the outpatient side of things, but especially in the surgical hospitals. But, you know, I think, you know, there's something to that, which is in the past, you know, inpatients in hospitals have driven further business into the ambulatory setting, including at USPI. You know, the hospital inpatient COVID environment has not really been, I mean, it's certainly down from what it was Q3 last year in terms of hospital inpatients. It's more just that the, you know, as you know, the Omicron variant wave kind of hit people on an outpatient basis, didn't necessarily make as many people sick on an inpatient basis. So there really wasn't crowding of our hospitals that pushed things into the ASC or outpatient surgery segment from that standpoint. But I don't know if you want to comment on outpatient surgery at USPI.

Yeah, I think as you looked at the Delta variant last year, we absolutely saw some pockets where we picked up some additional cases from some of the acute care hospitals. And there's places that we did see that. We would also see some disruption in our normal business. So on an overall basis, there was probably a slight positive given the acuity we would get from those cases. But overall, from a volume perspective, it was generally neutral.

Okay. All right. Thanks a lot.

Thank you. Next question is coming from Anne Hines from Azusa Securities. Your line is now live.

Hi, good morning. I just have a follow-up question on a question that you answered earlier on labor. I think you said you have a large number of union contracts that have been factored into labor going into 2023 and post that, excluding that, you're comfortable with 2% to 3% wage increases for that year. I guess first, is that what you said? And if it is, I guess, what gives you that level of comfort? Because we're just hearing higher wage rates going into 2023. And also, can you just talk about labor per segment? Like, what do you expect increases per segment? And then how much of your workforce is unionized would be very helpful as well. Thanks.

Hey, Ann. It's Dan. Let me address a couple of those points and then some can weigh in as well. In terms of the point about the union contracts, obviously with the union contract, you have the wages in place next year. And so we have obviously real good visibility into that. In terms of the non-union full-time employees, as we've mentioned over the past several quarters, we have been providing wage increases that have been at levels that, you know, higher than, you know, the typical level that, you know, we typically see. And, you know, the 2 to 3 percent is, you know, historically, you know, a pretty good marker in terms of the, you know, year-over-year increase in compensation for the employees. This year we've had to increase that in certain cases to obviously remain competitive. Where that significant tailwind could come from is by reducing contract labor, which is certainly much, much more expensive than full-time employee costs, Even if you're providing a wage increase above the two to three percent area, there's significant savings by converting that contract labor to full-time employment. And that's what the teams have been very focused on doing from a recruiting perspective and retention perspective. So that's where, you know, when we think about possible tailwinds for next year, further conversion of contract labor to full-time employment would drive noteworthy cost savings year over year. You know, and in terms of your question about the various segments, certainly you've seen we've put out the numbers in terms of what contract labor has meant across the portfolio. But, you know, from the USPI perspective, Contract labor, although the rates there in utilization have increased at USBI, the amount of contract labor in the USBI business is really insignificant compared to the acute care hospital business. It's less than 10% of the spend that we see in the acute care hospitals.

And the only thing I would add to that is the point I was making earlier was that Some of the base wage increases which may have been above the 2 to 3 percent level in order to stabilize the workforce and begin to set a platform to reduce contract labor in the future are more built into the run rate as we head into Q4 than our new items for the run rate that will develop sometime, you know, into 2023. Point being that we've been thoughtful this year, especially in the last couple quarters, about those type of adjustments where necessary as part of our overall workforce strategy.

And then, Ann, you asked a question about unionized labor, at least on the USPI side of things. We have one facility that's unionized labor.

Okay, thanks. Thank you. Next question is coming from Jason Casola from Citi. Your line is now live.

Great. Thanks. Good morning. Just around capital deployment priorities, you laid those out, which is helpful. You have that $250 million of M&A and de novo annual target for USPI, but can you help on how you're thinking about the allocation of the remaining three buckets as a percent of the free cash flow in the near term and how that might change over the longer term? Just any color or context around those capital deployment priorities as a percentage of free cash flow would be helpful.

Hey, Jason. Stan. Let me address that. In looking at things right now, we don't believe there will be any material change in our capital deployment priorities other than the fact that we are accelerating deploying capital for share repurchases. to now based on where the equity is trading. We had talked previously that we had intended, depending on market conditions, to evaluate allocating capital for share repurchases beginning in 2023. But given where our equity is trading, we've accelerated that and had the Board authorize a $1 billion share repurchase program. So, again, you know, it'll be, you know, a balanced approach. Given where the equity is trading, we will begin executing on our share repurchase program. But as I mentioned, the M&A pipeline for USPI is very strong, and we'll continue to allocate capital there, as well as to our hospital business to continue to enhance its more complex service offerings, as well as retiring debt when it makes sense and um you know there's obviously several tranches out there that um that we will target uh for debt retirement as well got it okay thanks thank you next question is coming from kevin fishbeck from bank of america your line is now live great thanks um i guess i wanted to ask about labor costs um kind of in two different ways i guess

The first one is, you mentioned that contract labor has not improved the way that you had expected it to improve as the year goes on. Are you attributing 100% of that delta to just how COVID has played out, or is there something structural? Because it seems to me like everybody is struggling more than they expected around labor this year, which I guess calls into question how much improvement we should assume into next year. And then Secondarily, around this contract labor improvement, it seems to me like that's probably part of the reason why you think volumes might be able to accelerate next year. If we don't get an improvement in the labor market, do you believe that's a headwind or would stop that accelerated volume into next year?

Thanks. Just real quickly, I think on the first part of your question, you know, there are certainly direct and indirect impacts of the environment we've been in because of the pandemic. There are obvious direct effects when you have staff that are out and you're procuring more contract labor. I mean, that's a very direct effect. But, you know, the impact, the indirect effect on the workforce, which is, I think, what you're really referring to as potentially more structural, is there as well, right? I mean, the workforce shortages that we face as an industry and certainly this year are not just due to individual covid spikes in people on quarantine and that that probably more than anything else is the driver of the contract labor rates not coming down the way we anticipated uh this year or and and really you know we're assessing that very carefully market by market going into 2023 how we would think about that tier you know to the second part of your question i mean if The labor market, from a contract labor standpoint, continues to be turbulent in 2023. We believe our strategy of being disciplined about contract labor utilization and making data-driven tradeoffs in where we will open up capacity and where we won't for volume in order to manage and maximize the earnings is the right way to go. That's proven to be the case for many quarters on end. And just because it wasn't the case in Q3 because we had an increase in contract labor is not a reason to question the successful strategy for a long period of time. And we'll continue to manage it that tightly if necessary through whatever part of 2023. This is still an issue that we face. I mean, at some point, that contract labor environment will begin to normalize and mitigate because of new graduates and other things entering the workforce that we're obviously spending a lot of time competitively trying to recruit into our system for the exact reason described, which is that we would like to have the ability to alleviate some of these structural challenges, not just react to the short-term COVID spike issues.

Thank you. Next question is coming from Josh Raskin from Nefron. Your line is now live.

Hi, thanks. Question on the ASC side as well. Was there anything to give us a sense on sort of specific types of procedures that were impacted? It sounds like it's more overall facility and physician, you know, sort of COVID hits, et cetera, not necessarily. But I'd be curious if there was anything that stood out in terms of types of procedures And do you think there's been any change in competition, you know, in terms of are you seeing more surgery centers, for example, in your markets or a change in the competitors? And then sort of lastly, any difference in these centers that have been acquired, built, you know, de novo over the last year or so versus ones that were more maturely owned?

Yeah. Hey, Josh. First, related to competition, no, I mean – The competition has been strong for the last several years. It continues to be strong. But as you know, we feel like we have a very good value proposition and continue to do very well as it relates to competing with other surgical facility companies, not only from an M&A perspective, but from an organic growth perspective. As it relates to specific specialties, I would say that some of the lower acuity specialties like ENT and ophthalmology and GI that were slower to recover as a result of COVID, some of those have started to come back. Specifically, ENT has come back pretty strong in the last couple of quarters. GI has come back strong. Ophthalmology has. But still, as we alluded to earlier, they're still only getting back to 2019 volume levels. So the only specialties that have really recovered beyond 2019 volume levels at this point, and I alluded to this earlier, RGI and ortho. And ortho is only slightly over 2019 volume levels. that's significantly over, and significant is relevant term, is GI, which is about 3% over 2019 volume levels. The others, again, are pretty consistent with 2019 thus far.

Okay.

Thank you. Our final question today is coming from Jamie Purse from Goldman Sachs. Your line is now live.

Hey, good morning, guys. I was wondering if you could talk a little bit about what you're seeing on the reimbursement side. First, can you give us your calculation of what you expect Medicare to be up for you specifically next year? And then on the managed care side, what are you seeing from your partners there? Are you getting incremental price? And if so, can you just kind of quantify that? And overall, between those two pieces and Medicaid, what do you expect pricing to be up for you next year?

Hey, Jamie. It's Dan. Let me hit that. In terms of Medicare pricing on inpatient fee for service side, the rate increase that went into effect October 1 is a little less than 4%. It's about 4% based on the final rule. In terms of on the outpatient side, after you take into consideration the 340B adjustment, its Medicare outpatient rate update will be pretty close to flat. From the commercial health plan side, what we're seeing, we like where we're at from a contracting perspective. What we anticipate in terms of moving through next year and beyond is rate increases with some acuity. as well in the, you know, 3%, 4%, 5% type of territory in aggregate. You know, some negotiations are a little better than that. Some negotiations are, you know, a little bit lower than that. But in aggregate, that's where we see commercial pricing.

Thank you. We've reached the end of our question and answer session. And, ladies and gentlemen, that does conclude today's teleconference. You may disconnect your lines at this time and have a wonderful day. We thank you for your participation today.