Tenet Healthcare Corporation

Good morning. Welcome to Tenet Healthcare's fourth quarter 2024 earnings conference call. After the speaker remarks, there will be a question and answer session for industry analysts. At that time, if you'd like to ask a question, please press star one on your telephone keypad. Tenet respectfully asks that analysts limit themselves to one question each. I'll now turn the call over to your host, Mr. Will McDowell, Vice President of 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 fourth quarter 2024 results, as well as a discussion of our financial outlook. Tenet Senior Management participating in today's call will be Dr. Sam Satoria, Chairman and Chief Executive Officer, and Sun Park, 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. And with that, I'll turn the call over to Saul.

Thank you, Will, and good morning, everyone. We delivered outstanding performance in 2024, characterized by strong same-store revenue growth, disciplined operations, and effective capital deployment. In addition, the year was highlighted by portfolio transactions that have transformed our franchise to be well-positioned for long-term growth with strategic flexibility and a deleveraged balance sheet. We reported 2024 net operating revenues of $20.7 billion and consolidated adjusted EBITDA of $4 billion, which represents 13% growth over 2023. Full-year adjusted EBITDA margin of 19.3% improved over 200 basis points from prior year. Our fourth quarter results were above our expectations, driven by continued same-store revenue strength, high acuity growth, as well as effective cost management. Our disciplined approach has enabled us to consistently exceed our performance expectations each quarter this year, furthering our track record. I would note that our full year adjusted EBITDA ended the year over $600 million higher than the midpoint of our initial expectations, driven by strong growth and operational performance. USPI had a fantastic year in 2024. We generated $1.81 billion in adjusted EBITDA, which represents 17% growth over 2023, and adjusted EBITDA margins of 40%. Same facility revenues grew 7.8% in 2024, another year substantially above our long-term goals. High acuity volume growth was highlighted by total joint replacements in the ASCs, up 19% over prior year. Importantly, customer service levels in our centers remained quite high as we earned a 96.6 overall patient experience score in 2024. Turning to our hospital segment, despite the sale of 14 hospitals during the year, we generated $2.185 billion of adjusted EBITDA in 2024, which represents 9% growth over prior year. Same-store hospital admissions were up 4.7%, as we continue to open up capacity to respond to a strong utilization environment. Acuity and payer mix were strong throughout 2024 and drove a 4.6% increase in same-store revenue per adjusted admission over prior year. This was an important year for Tenet as we transformed our portfolio of businesses through multiple, high multiple sales of 14 hospitals and related operations, generating $5 billion in gross proceeds and enabling significant balance sheet deleveraging. In addition, we added nearly 70 ambulatory surgical centers to the portfolio in 2024, as we were very active in both M&A and de novo development. And finally, over the past two years, we have returned capital to shareholders via share repurchase, retiring approximately 14% of our outstanding shares for $1.12 billion since our repurchase program began in the fourth quarter of 2022. Going forward, we plan to be active repurchasers of our shares, particularly at our current valuation multiples. These actions have resulted in a portfolio of businesses that is more predictable, capital efficient, and able to operate in a variety of environments with better margins and ample free cash flow for the benefit of shareholders. In summary, we're very pleased with our team's performance in 2024, and we believe that we will carry this momentum into the new year. Turning to 2025 guidance, we are projecting full-year 2025 adjusted EBITDA of $3.975 to $4.175 billion, which is an attractive 7% growth rate at the midpoint on a normalized basis. We anticipate adjusted EBITDA growth at USPI of approximately 8.5% at the midpoint of our guidance for 2025 based on our expectation of 3% to 6% growth in same facility revenue fueled by ongoing strength in demand and acuity, continuing effective operational execution, and additional sites of care joining the portfolio. We intend to invest approximately $250 million each year towards M&A in the ambulatory space and the pipeline of opportunities remains strong. We anticipate adding 10 to 12 de novo centers in 2025. Our ability to consistently scale our platform to create additional low-cost sites of care for patients and physicians continues to pay dividends as it improves our overall growth, profitability, capital efficiency, and resiliency in this regulatory environment. Turning to our hospital segment, we are expecting adjusted EBITDA growth of approximately 5.7% on a normalized basis at the midpoint for 2025. This projected growth is expected to be driven by 2% to 3% adjusted admissions growth and the strong operating discipline that our team has now demonstrated for many years. The hospital segment's performance will be enhanced by strategic capital deployment, expanded service lines, and further contributions from the new Westover Hills facility, which opened in the third quarter of 2024. Additionally, as we have noted, we have expanded the relationships that Conifer has with acquirers of hospitals we've sold, and this should contribute to growth in 2025. Finally, we acknowledge that there is currently a great deal of focus on the impact of potential regulatory changes in our space. We have demonstrated an ability to perform well in a variety of operating environments and believe we are differentiated from our peer set as we navigate potential changes going forward. For example, our ASCs operate with freestanding ASC rates, which insulates that important part of our business from potential changes in site neutrality rules. In summary, we had an outstanding year in 2024 and believe that we are in a great position for another strong year in 2025. Our guidance reflects the opportunities before us and the momentum that we carry into the new year. Our established management team stands ready to execute our focus strategy and deliver value for patients, physician partners, and, in turn, shareholders. And with that, Son will now provide a more detailed review of our financial results. Son?

Thank you, Som, and good morning, everyone. We are very pleased with a strong finish to the year. In the fourth quarter, we generated total net operating revenues of $5.1 billion and consolidated adjusted EBITDA of $1.048 billion, which represents an adjusted EBITDA margin of 20.7%, up almost 200 basis points from fourth quarter of 23. For full year 24, we generated $20.7 billion of total net operating revenues and consolidated adjusted EBITDA of $3.995 billion. These results were driven by strong same-store revenue growth, continued high patient acuity, favorable payer mix, and effective cost controls. I would now like to highlight some key items for each of our segments, beginning with USPI, which again delivered strong operating results. In the fourth quarter, USPI's adjusted EBITDA grew 14% over last year, with adjusted EBITDA margin at 42.1%. USPI delivered an 8.6% increase in same-facility system-wide revenues driven by high acuity levels and favorable pair mix. Same-facility system-wide surgical case volume grew slightly over last year. And turning to our hospital segment, fourth quarter adjusted EBITDA was $518 million with margins up 90 basis points over last year at 13.6%. Normalized for the divested hospitals, Adjusted EBITDA grew 13% over fourth quarter of 23. Same hospital inpatient admissions increased 5%, and revenue per adjusted admission grew 0.6%. Our consolidated salary, wages, and benefits in fourth quarter of 24 was 41.3% of net revenues, and our consolidated contract labor expense was 2.1% of SWV, both substantially lower than the 43% and the 2.8% respectively that were reported in the fourth quarter of 23. Next, we will discuss our cash flow, balance sheet, and capital structure. Our cash flow performance was very strong in 24 with $1.1 billion of free cash flow for the year. This includes the payment of $855 million in income taxes related to our completed divestitures. Excluding these tax payments, this represents nearly $2 billion of free cash flow for the year, or $1.3 billion of free cash flow after distributions to non-controlling interests, or NCI. For full year 2024, we repurchased 5.6 million shares of our stock for $672 million. We finished the year with over $3 billion of cash on hand with no borrowings outstanding under our $1.5 billion line of credit facility. Our year-end leverage ratio was 2.5 times EBITDA or 3.2 times EBITDA less NCI, a substantial improvement over the past year. reflecting the proceeds that we received from our hospital divestitures as well as our outstanding operational performance. We are very pleased with our ongoing cash flow generation and have a commitment to a deleveraged balance sheet. We believe we have significant financial flexibility to support our capital allocation priorities and drive shareholder value. Let me now turn to our outlook for 2025. We expect consolidated net operating revenues in the range of $20.6 to $21.0 billion. Our projected consolidated adjusted EBITDA is in the range of $3.975 to $4.175 billion. As a reminder, there are two normalizing items that I would call out when comparing our 25 adjusted EBITDA to the prior year. First, we reported $114 million of adjusted EBITDA from facilities that we divested in 24 and will not recur. Additionally, we reported $74 million of out-of-period supplemental Medicaid payments in Michigan and Texas in 24. After normalizing for these items, our 25 adjusted EBITDA is expected to grow 7% at the midpoint of our range. Our 25 outlook assumes continued growth in same-store volumes and effective pricing, as well as strong operational efficiencies and disciplined cost controls. Additionally, we anticipate further contributions from recent investments and partnerships in the hospital segment, as well as from M&A and DeNovo center openings at USPI. In addition, we are also assuming the following, same hospital admissions growth of 2% to 3% and adjusted admissions growth of 2% to 3%. And for USPI, same facility revenue growth of 3% to 6%. On a normalized basis, we expect adjusted EBITDA to grow 8.5% at USPI and 5.7% for our hospital segment at the respective midpoints of our guidance ranges. Our outlook also assumes $35 million of net revenues from the Tennessee Supplemental Medicaid programs. About one-third of this increase is related to the second half of 24 and is expected to be recorded in the first quarter of this year. Finally, we would expect first quarter 2025 consolidated adjusted EBITDA to be in the range of 24 to 25 percent of our full-year consolidated EBITDA at the midpoint. We anticipate that USPI's EBITDA in the first quarter of this year will be 21 to 22 percent of our full-year USPI EBITDA at the midpoint. Turning to our cash flows for 25, we expect cash flow from operations in the range of $2.5 to $2.85 billion, capital expenditures in the range of $700 to $800 million, resulting in free cash flows in the range of $1.8 to $2.05 billion. In addition, we're also assuming distributions to NCI in the range of $750 to $800 million, which would result in free cash flow after NCI in the range of $1.05 to $1.25 billion. And finally, as a reminder, our capital deployment priorities have not changed. First, we will continue to prioritize capital investments to grow USPI through M&A. Second, we expect to continue to invest in key hospital growth opportunities, including our focus on higher acuity service offerings. Third, we will evaluate opportunities to retire and or refinance debt, And finally, we'll have a balanced approach to share repurchases, depending on market conditions and other investment opportunities. Given our attractive free cash flow profile and current valuations, we plan to be active repurchasers of shares in 2025. In conclusion, we had an outstanding year in 2024 with effective operational execution, robust growth, and a transformed portfolio of businesses. We're confident in our ability to deliver on our outlook for 2025, and continue to drive value for patients, physician partners, and shareholders. And with that, we're ready to begin our Q&A. Operator?

Thank you. At this time, we'll be conducting a question and answer session. If you'd like to ask a question, please press star 1 on your telephone keypad. As a reminder, we ask that you please limit to one question. A confirmation tone will indicate your line is in the question queue. You may press star two if you'd like to remove your question from the queue. One moment, please, while we poll for questions. Our first question comes from Peter Chickering with Deutsche Bank. Please proceed with your question.

Good morning, guys. Thanks for taking my question. So looking at tenants in the last few years, the biggest change has been the cash flows and your deleveraging. Your cash flow guidance for this year is up 90% year-over-year with nearly a billion dollars more cash flow from operations. So looking at your cash flow guidance for this year after NCI, it's about $1.15 billion at the midpoint. If we pull out $250 million for M&A, it's about $900 million left to deploy. With your leverage at sort of 3.2 times EBITDA less NCI, can you refresh us on what your ideal target leverage ratios are And should we be modeling the rest of that going to share repo at this point? Thank you.

Hey, Peter. It's Tom. First of all, I appreciate reiterating the improvements that we've made in generating free cash flow from this business from operations. It's obviously been a very important part of our goal over the last few years and getting to this point probably earlier than we thought. We're very comfortable with the leverage that we operate at today, and importantly, it gives us – you know, we look at it and say it gives us significant strategic flexibility with respect to the business, both in terms of activity that we may pursue in growing and scaling USPI, as I noted in my comments, but also from the perspective – especially, as I said, at these valuation multiples – you know, in terms of share repurchase. And both Son and I noted that, you know, we would plan to be active repurchasers of our shares at these multiples. Makes complete sense. We don't have debt coming due for a couple of years, right? I mean, so we're not in any situation of urgency there regardless. And I think the return on share repurchase at this point would be higher anyway. So, Our thinking is relatively clear about that in the coming years. Obviously, we need to continue executing operationally with the track record that we've built to generate that free cash flow. But as we've talked about in the last couple of years, we've really hardwired our approach there. The last thing I would point out, in addition to what I said about USPI in my comments, You know, we don't, USPI does not have a tremendous amount of Medicaid exposure. So, you know, when you think about utilization of our cash flows and, you know, regulatory risks that may be out there, I mean, the reality is half our EBITDA is generated in a segment that isn't really facing risk from, you know, any scenario out there related to Medicaid programs. And that's very helpful. It's very different than it might have looked five or six years ago. So we feel confident about the valuation opportunities for the company.

Thank you. Our next question comes from Jamie Purse with Goldman Sachs. Please proceed with your question.

Hey, good morning. Thanks for taking the question. Can you maybe spend a minute on just the volume environment that you're seeing today? Obviously 2023 and 2024 were pretty strong years. Some of that just, you know, recovery and normalization post the pandemic. Where do you think we're at from a volume perspective today? And how do you expect volumes to progress throughout the course of the year?

Yeah, thanks, Jeremy. I mean, the simplest statement I would make right now is that, you know, we've anticipated the volume environment continuing to be strong coming into 2025. I mean, that's the simplest summary statement I would make. There aren't obvious trends from December 31st to January 1st that appear to have changed. I mean, the coverage environment looks good. The employment environment looks good. demographics, both in terms of areas where at least our portfolio is now positioned relative to where it was, has attractive demographics. And, you know, as we've noted, we've had opportunity to expand capacity and take on that capacity without excessive cost to do so. And we're doing it in a deliberate way. So we, you know, I mean, our guidance, reflects that we feel pretty good about, you know, going into 2020-25. Okay. Thank you.

Our next question comes from Brian Tandewa with Jefferies. Please proceed with your question.

Hey, good morning, guys, and congrats on the quarter. Maybe some, as I think about your comments on Medicaid and USPI, just Curious how you're thinking about the risk overall for the company from all the political headlines that are out there and what the Republicans are trying to do with changes to healthcare policy and what you're doing to prepare for that, just for that potential change, whether it's Medicaid or health insurance exchanges across both business lines. Thanks.

Yeah, thanks, Brian. A few things. So, I mean, first of all, the fundamental underpinnings of success in an environment with any kind of uncertainty in our view is operating discipline in what we do, right? And the other important underpinning is having a clear understanding of the economics of our business internally, meaning we understand clearly our service lines, our markets, etc., that may have greater dependency or less dependency upon certain types of supplemental payments, where, for example, the strength in the exchanges has contributed to earnings, et cetera. So the combination of the operating discipline and the insights about the business probably give us an opportunity to manage and pivot as needed, depending on what happens. You're right, the segments are different. I mean, I, you know... We've taken the opportunity over the past few years to create resiliency in USPI by making sure that the ambulatory surgery centers as a part of USPI are on freestanding rates. The Medicaid exposure is de minimis in that business, and that's very helpful from that perspective. And the exchange business there has had less impact than it's had on the acute care segment in terms of the exchange growth. from that perspective. So from a USPI perspective, look, this is all about an important tailwind of moving things into a lower cost setting in an expensive portion of the healthcare industry, which is surgical care, right? And doing so in a way where we're constantly increasing the acuity of the work at USPI because it creates more value for the purchaser. On the acute care hospital side, I think it's important to continue to search for efficiencies that allow us to generate margins. We always talk about the concept of Medicare profitability. Can you generate margins on Medicare reimbursement in order to have a metric out there for efficiency goals that you would create? Because it's important to be able to operate in that type of environment. Specifically on the acute care side, the number one adaptive action today is helping the regulators understand the importance that these programs provide for basic access for people that wouldn't otherwise have access to care. And that's really important because if that shapes or is a factor in shaping policy for I think that what comes out of that policy will likely be manageable for us and something that we can get behind. I'm not sure that right now taking a bunch of actions to restructure the business is the right thing to do. I think there's a very strong case to be made that many of these things are really critical to providing access And it happens to be that that access is also being provided in states with voters that really matter to this administration, and that's an important supporting factor as well.

Our next question comes from Andrew Mock with Barclays. Please proceed with your question.

Hi, good morning. When I look at the ASC case mix from 23 to 24, it doesn't look like there are significant mix changes. We actually see MSK down one percentage point and ophthalmology up one percentage point, but you're increasing acuity significantly to the point where you're seeing high single-digit same-store revenue growth without meaningful case growth. So can you speak to the types of cases driving acuity higher? Because it's not obvious from the case mix disclosures. Thanks.

Yeah, no problem. I mean, just to clarify, the orthopedics, line item has a lot of things in there. That's why we call out the highest acuity work in joint cases, for example, which is where you have the hips, knees, obviously the shoulder expansion. That's where the acuity is actually growing. I mean, remember, when you look at certain low acuity procedures that we may do in ASCs, the revenue per case is, you know, an eighth or a ninth of a single joint case, total joint case, from that perspective. So, I mean, we're doing exactly what we wanted with the business, which is we're growing the acuity, we're growing the net revenue per case. You know, we are reducing exposure to high-volume, low-revenue cases. In some cases, things that could also be done in offices that... that further strengthen the resiliency and value of what USPI is building. So that orthopedics line item has a lot of things in there from high acuity to low acuity cases. And it's the reason we call out the really high acuity work. It's a fundamental driver of the net revenue per case strength, which you're seeing.

Great. Thanks for the call.

Sure. Sure. Our next question comes from Justin Lake with Wolf Research. Please proceed with your question.

Thanks. Good morning. A couple things, just numbers-wise. Maybe you could tell us, you know, you've mentioned Tennessee as a tailwind at $35 million. You mentioned, you know, for instance, Michigan, you're going to have a little bit of a one-time headwind there. Right. When you think about X, those issues, kind of core DPP dollars year over year, can you tell us what's assumed in the guidance? And then same for exchanges, like what kind of exchange growth do you kind of expect in your markets, exchange volume growth within that guidance? Thanks.

Hey, Justin, it's Sun, and thanks for the question. On your question about supplemental payments, yeah, I think you called out the kind of the one-timers that we've referenced. You know, the other point in fiscal 24 is we still had a little bit of value from hospitals that were then divested during the course of the year, but, you know, that's mostly in Q1. So there are a couple of those moving factors. But in fiscal 24, we generated about $1.16 billion of Medicaid supplemental payments. Going into 25, our guidance assumes something pretty consistent with that, you know, You mentioned the Tennessee one-timer, but excluding that, we're pretty consistent year-over-year. On your question about exchange, you know, as we've said multiple times, total emissions and revenues from exchange population was a strong growth driver in 2024. You know, we expect that to continue, per Sam's earlier comments around the overall volume environment. You know, the enrollment, the renewal cycle seems to have been positive. We'll see how much of that turns into actual revenue you know, in missions. But, you know, we certainly won't see the, you know, 40%, 50% growth that we saw in 24, but we still continue to see a strong environment. You know, just as an example, our strategy, long-term strategy, has always to be, you know, in broad networks from a contracting standpoint as an example. So we see, you know, good things for 25. Thanks for the question.

Our next question comes from Benjamin Rossi with JPMorgan Chase. Please proceed with your question.

Hey, good morning. Thanks for the question here. So, just across supplies, we're seeing some pressure here as a percentage of revenue with that category increasing about 100 bps year-over-year to 18.3. How would you characterize your current supply dynamics in the quarter? Is there anything discreet occurring within there, or is this largely a byproduct of your push to higher acuity? Kind of curious where you're seeing that number settling out in the steady state during 2025. Thanks.

Yeah, hey, Ben. Yeah, I think it's what you said on the latter piece. It is just kind of parceled with our acuity strategy, so the supplies will go up, you know, as a percentage a little bit in Q4. But over the year, we've been pretty well balanced, and we expect it to be, again, balanced in 2025.

Got it. Thanks.

Thank you.

Our next question comes from Joanna Gajic with Bank of America. Please proceed with your question.

Joanna Gajic Hi, good morning. Thanks so much for taking that question. So on the guidance element and both there is same-store revenue, 3% to 6%, right? That seems to be sort of more like a normalized growth, right, because clearly you grew very nicely in 24, almost 8%. So is it just conservatism? You know, could it maybe also break down volumes versus pricing that's included in that range? Thank you.

Yeah, hey, it's Tom. Look, a couple of things there. First of all, you know, long term, as we've learned with USPI, and I think we've shared this data before, we've looked at 10 years worth of USPI's performance And same-store growth rates of around 4% to 6% is what we guide to. Now, history suggests over that 10-year period, we've performed at the upper end of that range, 6%. That, you know, has looked better strengthened over the last five, six years, actually, over that average period, okay? So... You point out this year almost, or this year, past year, 24, 7.8%. The prior year was 9.2% growth rate. So we're running very hot from that perspective in terms of long-term averages with respect to USPI. So our guide just brings us right back to what our long-term growth rate is. You know, in terms of the year to year, as you've seen, it can be lumpy, right? Twenty-three, huge volume growth. Twenty-four, more growth in acuity and intensity. And part of what we're signaling for 25 is it's definitely our plan to continue this shift to higher acuity procedures. You know, I started to point out some of the factors driving that in terms of the revenue intensity of some of these cases. how efficiently we're able to do them in our operating rooms now and generate margin, how we are scaling those programs into more centers. We now have robots in almost 150 of our programs around the country. This is the direction in which we're taking the organization. And so, yeah, the guidance reflects kind of our long-term average, but We've obviously been running quite a bit above that.

Our next question comes from AJ Rice with UBS. Please proceed with your question.

Hi, everybody. I thought I would ask maybe on where you're at with managed care contracting. I know we've been in a period where you've been getting a little bit toward the high end of historical rate updates to pay for some of the labor challenges in the last few years. It's 25 a year in which you'll still see that type of dynamic, maybe where you're at in terms of signing up contracts. And then also on the managed care side, any update on thoughts about denial activity, prior authorization challenges, other term changes that you're dealing with?

Yeah, why don't we take those in reverse? I mean, I would say that the environment is no different than it has been. I mean, there's a constant back and forth of administrative costs that goes into adjudicating claims that probably is unnecessary, but obviously both sides have a point of view on that. You know, what I would say more importantly than anything else from our perspective is the work that Conifer does in driving initial disputes to a very, very attractive low rate of denials is critical. And our skill set in doing that in both working collaboratively with the payers and adversely where needed on the basis of solid documentation, appropriate coding, compliant coding, and efficient revenue cycle operations has made a big difference. We're seeing a gap in what we generate in terms of lower denial rates than the industry from what we are seeing with respect to initial dispute rates. And that's good because that means we're doing things right in generating the appropriate cash flow from the work we're doing. Son, maybe you want to comment on the managed care side.

Thanks, Tom. AJ, for your first part of the question, as we've said historically, we are continuing to see commercial rates increases in the 3% to 5% range, and some of the contracts have been at or slightly above the high end of that range as respect to the inflationary pressures that you've mentioned. So I think the overall situation there is pretty consistent. And then in terms of contracting, Going to 25, we're over 90% contracted for 25 and probably about over 50% contracted for 26 as well. So we have great visibility into 25 and beyond.

Thanks for your question. Our next question comes from Stephen Baxter with Wells Fargo. Please proceed with your question.

Hi, thanks. I wanted to come back to the same store hospital volume guidance for 2025. I appreciate you're still expecting exchange growth inside of that number to some degree. I would also love to hear any quantification you can offer about how much hospital capacity you'll have online in 2025 compared to 2024, trying to break out that 2% to 3% and maybe think about maybe what's the market level growth inside of that compared to how much of it's coming from capacity. Thank you.

Yeah. Hey, Stephen. It's It's obviously both. I mean, the majority of that is the market level demand that we're seeing versus, you know, the selective markets in which there's still capacity that we're bringing online. But it is a contributor, which is why I called it out before. We haven't quantified, you know, what that looks like between the two numbers. But it is both, and the majority of it is market-based demand across the board. Some of this is also related to the service line choices we make, of course, which have higher growth rates. The things that we're doing that are taking care of people with multiple chronic illnesses that continue to grow in prevalence are continuing to create more demand than perhaps certain types of lower acuity work, which may be coming out of hospitals in our environment. And so that's really how we think about it. in terms of the growth rates. Yeah, look, it's been a very busy year in the acute care environment. And as I said, I think the most important thing we're taking into the year from a mindset perspective is we're not seeing changes in the demand patterns. You know, that was a comment that to Jamie's question earlier, we're not seeing changes in the demand pattern right now, you know, and so, I mean, I'm not going to go forecasting what we may see in the later part of the year, but, you know, we're not seeing that right now.

Our next question comes from Michael Ha with Baird. Please proceed with your question.

Hi, thank you. Just a quick clarification first and then my real one, and apologies if I missed it, but your USPI at 3% to 6% growth guide, what's the volume versus pricing split on that? And then my real question, I'm sorry to add one more question on policy, and I understand USPI is minimal Medicaid exposure, but for your hospital and maybe taking a different approach, just given all the news flow, NIH cuts, DOGE's potential focus on Medicaid, administrative costs. If DOGE were to implement those cuts, it might not be overly impactful, but still perhaps a couple percent of overall Medicaid spend. So I'm curious to hear your view. If that were to happen, how do you think states might react? What's your view on the likelihood that states might potentially slow that Medicaid cut down to provider rates and impact tenant and hospitals more broadly? Thank you.

Yeah. A couple of different things. So let's just start with the business side of it first with respect to USPI. As I indicated, there's no long-term deviation from our approach of thinking about, you know, half and half roughly managed care and volume at USPI. But because it's lumpy and it's proven to be lumpy, we're not guiding it. specifically for the year with respect to that. And you can understand that. I mean, we're successfully now two years in a row, you know, executing our strategy of increasing lower volume, high acuity cases. And in fact, as you can tell from our, you know, quarterly beats consistently, we're exceeding what we expect from the standpoint of what we can do in same-store revenue growth in that environment. And so we're pleased by that, that, you know, we can do that. We obviously had a little bit of fits and starts around that a few years ago in terms of how we were executing it, but we got it right and it's working, and, you know, I'm really pleased with that. So the long-term algorithm is the same, but, you know, from a short-term standpoint, you know, we're giving you the revenue guidance with obviously the track record of it being, you know, stronger. I don't, you know, on the policy side... I think to be clear, like we don't have, you know, even in our academic medical center enterprises and affiliations, we don't have significant NIH or NSF indirect grant cost exposure in our business. So in particular, you know, as you can imagine, when we saw that, We thought about that in our environment and where we had R01 grants and other things within our environment, but we don't have that significantly in our environment. I think the broader question of Medicaid policy and other things is an important one, but look, the focus that is articulated, and you can't tell what's going to happen, but the focus that's articulated on... reducing fraud and abuse, including in some of the public comments made yesterday all the way in the Oval Office, I think one thing that people may find is that Medicaid redeterminations over the last couple of years have probably done a lot to reduce the number of people eligible or not eligible who happen to be on Medicaid. And so I'm you know, again, no way to predict for sure, but I'm somewhat, you know, comforted by the fact that some of that work has already been done through this redetermination process. So, you know, we'll see where this goes and what remains to be seen. Finally, as to speculation, speculating on what the state's responses may be, I think the states are going to be important allies across the board in in advocating for uh... the dollars that come through these medicaid uh... partnerships with the federal government because again i go back to this is the only way to create access for the people that need it that are on medicaid uh... you know this is not some program that's generating incredible windfalls for health systems uh... on that basis the unit reimbursement is still below the cost of that care And so I think that that's gonna be an important balancing factor. The states will play an important role in this.

Our next question comes from Anne Hines with Mizuho. Please proceed with your question.

Hi, good morning. So I know there's some big surgery center assets out there on the market. Can you remind us, given your delivered balance sheet, what your appetite is versus larger scale M&A in the surgery center business?

Hey Ann, it's Tom. Obviously I'm not going to comment on any kind of M&A opportunities. We're very aware of everything that's available in the market. We've proven our ability over the last few years to deploy M&A capital both on a, you know, single asset basis and large multi-center asset acquisitions. I would tell you that the first year post our acquisition, you know, early last year of the portfolio that we took on went better than we thought it would. So that's, you know, that's good news. And, you know, as I said early on in my comments, our balance sheet provides us plenty of flexibility to to approach things. But look, we're disciplined. We believe in growth businesses. We believe in areas in which we can add value. And we have a lot of flexibility given our cash flow generation and valuation multiple to deploy cash for the benefit of shareholders in multiple different avenues at this point.

Our next question comes from Whit Mayo with Lorinc Partners. Please proceed with your question.

Hey, good morning. Just to stick on USPI for a second, are there any new health system partners that we may not be aware of in the last year? I know you've been selective and disciplined with the financial strength of the partners that you want to work with, but I'm just not sure I've had an update or heard an update on anything new or any expanded relationships with any health systems in some time, and maybe just a broader comment on the de novo activity, the 10 to 12 this year, any of those with new partners or those all existing partners? Thanks.

Yeah, hey, Wade, it's Tom. Now, we haven't provided any updates on health system partners and other things. And remember, I mean, our platform is such that we work just as effectively with partners as we do without partners because of our ability to generate contracts contract synergies, managed care, supply chain, everything, right, in our management capacity for these assets. So we're growing the portfolio with both vectors, and I don't think that's going to change. I mean, I think, you know, the expansion of de novo assets can occur in many different ways. Some are in existing markets. Some are in new markets. Some are with MSOs that are expanding their physician side footprint. And as I've said in the past, I've realized that there isn't a better operator of ASCs to generate margin from those investments for those doctors than USPI. So that's another vector of growth that is helping to create de novo activities. It's a multi-pronged growth strategy, and I don't think that's really going to change looking forward.

Our next question comes from John Ransom with Raymond James. Please proceed with your question.

Hey, good morning. So I'm not predicting you'll hate this question, but bear with me. So we've heard from a few folks that – the fourth quarter seasonal uptick is not quite what it used to be because just the fact that deductibles have gotten so high, particularly in commercial plans. Do you think there's any evidence of that?

John, are you referring just care delivery overall or USPI specifically?

I meant electives. So electives either in the hospital or in the USPI.

Yeah, elective work. Yeah. Well, you know, I mean, again, I'm not sure that I'm going to be able to give you a statistically significant answer, but I would say that, you know, the seasonality in Q4 and especially as that ramps into Q1 on elective surgery is it has tempered a bit. I mean, Q4 is still a more productive quarter. Our asset utilization in our USPI segment does go up still in Q4, but it has tempered a bit overall. And also, you know, and how much of it is the deductibles versus somewhat the impact of, you the impact of just some of these weather events, uh, were, were, were relevant. Um, and so how much of it was, you know, a seasonality shift versus some of the weather events that we, I don't know. I don't know that we've really calculated that. Um, but it is, I mean, you're, you're picking on, you're picking up on something that we've sort of said, huh, intuitively it feels a little bit different, but the general pattern hasn't changed.

And so just my follow-up, and thanks for that answer. If we look at 23 and 24, you know, utilization was up for – in 23, I'd say electives. In 24, there was a bunch of other stuff going on, like two-midnight rule and cancer cases and what have you. Do you think – again, probably you can't answer this question, but it seems to us like 25, we're kind of back to more kind of a normalized year where maybe we've cleared out all the COVID backlogs. and we're kind of clear all of these kind of wonky events in 23 and 24. Is that kind of your, is that what's implied in your guidance? Is that, that's kind of where we are?

I mean, that is kind of, I mean, at some point we have to get back to an environment where we're not explaining everything either on the basis of COVID or post COVID or whatever the case may be. You know, no one ever gets that entirely right, but I do think that, That is a little bit of what the guidance implies. And as I said, I think that's a fair way to plan for the year. And yet at the same time, I don't see shifts necessarily in the strength, the strong demand environment that we saw in 24 yet in particular. So we'll see how that plays out.

Thank you.

Thanks.

Our next question comes from Josh Raskin with Nefron Research. Please proceed with your question.

Thanks. I'm going to stick on the USBI topic. So can you speak maybe to the broader competitive landscape for ASC transactions? Are you seeing more competition and if you could differentiate between larger sets of assets or even one-offs or even competitors developing de novos in your markets and then In your prepared remarks, Sam, you mentioned the de novo growth. Is that indicative of more what we'll call sort of organic center expansions as opposed to acquired centers?

Well, let me go in reverse. Look, we think de novo development activity is really critical, and we've been focused on that and scaling that up. I mean, again, part of our thinking here, Josh, is that consistent with our move into more high-acuity ambulatory surgical work, de novos also represent a significant value shift in markets, right? Because usually what you're doing is you're building from the ground up, you're moving things into a lower-cost setting. It's value for the consumers and payers in the markets to be focused on de novos in addition to everything else that we may be doing to grow the and expand the high-acuity services. So it's part of our value strategy there, and maybe that's why you're seeing more of it from the de novo side. In terms of the competitive landscape, no, I don't think the competitive landscape has changed. I mean, you know, the easiest way to assess the competitive landscape is to just count the center counts across different organizations, and some are scaling better than others. and that probably more than anything reflects competitive, the output of whatever competitive intensity exists. We've been pretty pleased with our ability to scale win competitive situations and processes where we want them and maintain high quality, high profit margin centers. And, you know, we always assess that pipeline every year. The pipeline still looks good for doing that.

That's helpful. Is it fair to assume that the de novo long-term returns on capital are higher?

Yes, of course. Yes, because, again, it's not like building an acute care facility, right? The building costs are low. It's a shorter time frame once the partnership is syndicated. There's work up front in syndicating the partnership that takes time, but that's not a capital-intensive activity. Look, I think at the start of this, Pito pointed out one of the big changes in the organization around the generation of free cash flow. We also focus on measuring and following our overall return on invested capital within the organization. And obviously, the more we shift into this ambulatory segment, the more that gets better. And obviously, the more we do de novos, we see that that gets better in terms of what we're doing in the business when we're deploying our cash. Yeah, you're absolutely picking up on what we're doing for the right reasons.

Thanks. Our next question comes from Matthew Gilmore with KeyBank Capital Markets. Please proceed with your question.

Hey, thanks. I wanted to follow up on the cost management and efficiency comments. You know, the company's clearly made a lot of progress the last few years, and you noted the SWB and contract labor metrics. As you look ahead, are there any areas of particular focus that are going to continue to drive efficiency in 2025 and beyond that you'd highlight for us?

Sure. I mean, I think that the cost management agenda doesn't change in terms of managing labor, managing supplies, managing purchase services, active vendor consolidation. activities scaling our service lines in which we've got a cost structure that we're comfortable with obviously just that scale creates opportunity you know I've I've said in the acute care segment I've said all along we're really pleased with the improvements that we've made in so many of the metrics from the standpoint of cost, labor, overhead, supplies, purchase services, relative to, you know, our peer set in the industry. Obviously, we always continue to note that an area that we can improve is our asset utilization. And that's, you know, obviously in comparison to what we look at as kind of the gold standard out there. So that's That's really an area that we're continuing to work on as we expand capacity and build volumes into some of the facilities that we took capacity offline during the pandemic from an efficiency standpoint. Our global business center has contributed significantly. to our cost savings. If you think about the last four or five years, the journey we've been on, of course, there's obvious unit cost savings that you see on an immediate basis. But there's a lot of cash flow that goes into actually restructuring and building and scaling that enterprise. And what might have started with kind of commodity work in certain areas of finance or accounts receivable has expanded to 10, 12 different service lines that we are now running effectively in the global business center. Clinical areas, clinical analytics, you know, physician credentialing, a variety of things. And that's an important part of our efficiency agenda as we look forward as well. And it's, you know, now that it's obviously well past break-even cash flow, those savings materially contribute to what we're doing.

Got it. Very helpful. Thank you.

Our next question is from Ben Hendrix with RBC Capital Markets. Please proceed with your question.

Hi. This is Mike Murray on for Ben. Thanks for taking my question. So ASC total joint procedures grew nicely in 2024. I wanted to hear your expectations for growth in 2025 and beyond, and then cardiology procedures have been the latest slated to drive material growth in ASCs. Can you discuss any early progress there, and when do you see these procedures really accelerating? Thanks.

Yeah, hey, it's Sam. We obviously, we anticipate continuing to focus on our orthopedics line of business going forward. We're not going to guide service line level volumes from that perspective. But we still think, obviously, there's a tailwind in ambulatory surgical growth from an orthopedic standpoint. And that's both the stuff we're doing today and expansion of the procedure set that could be done safely in an ASC. Same with cardiac. I mean, as I've said all along, the the opportunity in a wide variety of cardiovascular procedures is there. I've always been clear that I think that that opportunity will proceed more slowly than people anticipate because of important patient safety considerations and payer mix considerations, and also the capex required to build a cardiac center is very different than building a other types of ASCs, given the equipment that you have to have in there. So the upfront investment for the physician partners and other things is much higher with potentially lower margin assets. And so from economic reasons and patient safety reasons, I think this market will evolve, but I think it will evolve slower than people like to think. And, you know, we'll obviously be participants in that as we are today, but we're also... We're not going to try to rush it and sacrifice patient safety and quality in that regard.

That's helpful. Thank you.

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