Tenet Healthcare Corporation

Good morning. Welcome to Tenet Healthcare's second quarter 2025 earnings conference call. After the speaker's 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 1 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 Tenant's second quarter 2025 results, as well as a discussion of our financial outlook. Tenant 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 Sam.

Thank you, Will, and good morning, everyone. The second quarter continues our track record of strong outperformance in each of our businesses. We reported second quarter 2025 net operating revenues of $5.3 billion and consolidated adjusted EBITDA of $1.121 billion, which represents growth of 19% over 2024. Second quarter 2025 adjusted EBITDA margin of 21.3% represents a 280 basis point improvement over the prior year driven by strong same store growth and very efficient operating performance. USPI continues to deliver. We generated 498 million in adjusted EBITDA, which represents 11% growth over second quarter 2024. Same facility revenues grew 7.7% in the second quarter, highlighted by a 12.6% growth in total joint replacements in the ASCs over the prior year. We added eight new centers in the quarter, including facilities specializing in high-acuity procedures such as spine, orthopedics, and neurosurgery. We continue to see a robust pipeline for M&A opportunities and expect to exceed our baseline intention for $250 million of M&A spend in 2025. Turning to our hospital segment, adjusted EBITDA grew 25% to $623 million in the second quarter of 2025. Same-store hospital admissions were up 1.6% in the quarter. Second quarter 2025 revenue per adjusted admission was up 5.2% over the prior year as payer mix and acuity remained strong. We are making significant investments to expand our network to support growth in our markets and have confidence that the demographic trends our high acuity service line priorities, and our efficient operating platform can generate ongoing returns in this segment. We have also reduced overhead given we downsized our hospital portfolio. Our results in both segments exceeded our expectations and extend our track record of consistently strong fundamental execution. We continue to capitalize on our compelling valuation and have deployed $1.1 billion to repurchase 7.2 million shares in the first half of 2025. As we noted in our release, the Board of Directors has authorized a $1.5 billion increase to our share repurchase program. Turning to our full year guidance. At this point in the year, we are raising our full year 2025 adjusted EBITDA guidance to a range of 4.4 to $4.54 billion, which represents an increase of $395 million, or 10% roughly, at the midpoint of the range of our prior guidance. The guidance increase is supported by fundamental strength in our businesses and expectations for continued growth. In summary, we continue to deliver on our commitments to a strong balance sheet and significantly improved free cash flow generation. Finally, in closing, we are committed to a culture of quality, transparency, and compliance. This culture permeates our business and is reflected in the dedication of our colleagues and caregivers that go to work each day to care for our patients and communities that we serve. We are pleased that these are the values that we have instilled into our organization, which continue to drive results and outperformance. And with that, Son will provide a more detailed review of our financial results. Son, turning it over to you.

Thank you, Sam, and good morning, everyone. We delivered strong results in second quarter of 2025 with adjusted EBITDA well above the high end of our guidance range, driven by strong fundamentals, including same-store revenue growth, continued high patient acuity, favorable payer mix, and effective cost controls. We generated total net operating revenues of $5.3 billion and consolidated adjusted EBITDA of $1.121 billion, a 19% increase over second quarter 2024. Second quarter adjusted EBITDA margin was 21.3%, a 280 basis point improvement over prior year. 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 second quarter, USPI's adjusted EBITDA grew 11% over last year, with adjusted EBITDA margin at 39.2%. USPI delivered a 7.7% increase in same-facility system-wide revenues, with net revenue per case up 8.3% and case volumes down 0.6%, reflecting our continued disciplined shift towards higher acuity services. Turning now to our hospital segment, Second quarter adjusted EBITDA was $623 million, with margins up 300 basis points over last year at 15.6%. Same hospital inpatient admissions increased 1.6%, and revenue per adjusted admissions grew 5.2%. Our consolidated salary, wages, and benefits was 41% of net revenues, a 140 basis point improvement from the prior year. and our contract labor expense was 1.9% of consolidated SWB expense. This improvement has been driven by our data-driven approach to capacity and labor management and disciplined operating expense controls. Finally, we recognized a $79 million favorable pre-tax impact for additional Medicaid supplemental revenues related to prior periods in the second quarter of 2025. This includes the recently approved program in Tennessee. As a reminder, our second quarter 2024 results included a $30 million favorable pre-tax impact for additional Medicaid supplemental revenues related to prior year. Next, we will discuss our cash flow balance and capital structures. We generated $743 million of free cash flow in the second quarter, and as of June 30, 2025, we had $2.6 billion of cash on hand with no borrowings outstanding under our $1.5 billion line of credit facility. Additionally, we have no significant debt maturities until 2027. And finally, during the second quarter, we repurchased 4.6 million shares of our stock for $747 million. And year to date through June 30th, we have repurchased 7.2 million shares or $1.1 million. Our leverage ratio as of June 30, 2025 was 2.45 times EBITDA or 3.11 times EBITDA less NCI, driven by our outstanding operational performance and continued focus on financial discipline. We are very pleased with our ongoing cash flow generation capabilities and remain committed 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. For 2025, we now expect consolidated net operating revenues in the range of $20.95 to $21.25 billion, an increase of $300 million over prior expectations. As Sam mentioned, we are raising our 2025 adjusted EBITDA outlook by $395 million at the midpoint to $4.4 to $4.54 billion, reflecting the strong fundamental performance of our business. At the midpoint of our range, we now expect our full-year 2025 adjusted EBITDA to grow 12% over 2024. At USPI, we are now expecting 2025 adjusted EBITDA of $1.99 to $2.05 billion, a $70 million increase over prior expectations. In addition, we have increased our assumption for same facility USPI revenue growth by 100 basis points to 4% to 7% for 2025. In hospitals, we are raising our 25 adjusted EBITDA outlook range by $325 million at the midpoint to $2.41 to $2.49 million. Additionally, we are lowering our assumption for same hospital adjusted admissions growth by 50 basis points to 1.5% to 2.5%. for 2025. Finally, we expect third quarter 2025 consolidated adjusted EBITDA to be in the range of 22.5% to 23.5% of our full year consolidated adjusted EBITDA at the midpoint. We expect third quarter 2025 USPI EBITDA to be in the range of 23.5% to 24.5% of our full year USPI adjusted EBITDA at the midpoint. Turning to our cash flows for 2025, we now expect free cash flows in the range of $2.025 to $2.275 billion, distributions to non-controlling interest in the range of $780 to $830 million, resulting in free cash flow after NCI in the range of $1.245 to $1.445 billion, an increase of $195 million at the midpoint of our range from prior outlooks. Turning now to our capital deployment priorities, we are well positioned to create value for shareholders through the effective deployment of free cash flow, and our priorities have not changed. First, we will continue to prioritize capital investments to grow USPI through M&A. Second, we expect to continue investing in key hospital growth opportunities to fuel organic growth, including our focus on higher acuity service offerings. Third, we will evaluate opportunities to retire and or refinance debt, And finally, we'll continue to have a balanced approach to share repurchases, depending on market conditions and other investment opportunities. As Sam noted, our Board of Directors has recently authorized a $1.5 billion increase to our share repurchase program. We continue to deliver consistent growth and have disciplined operations, which has translated into outstanding financial results. We are confident in our ability to deliver on our increased outlook for 2025 as we continue to provide high-quality care for those in the communities we serve. And with that, we're now ready to begin the 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, tenant respectfully asks that analysts limit themselves to one question each. 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. For participants using speaker equipment, it may be necessary to pick up the handset before pressing the star keys. One moment, please, while we poll for questions. Our first question comes from AJ Rice with UBS. Please proceed with your question.

Hi, everybody. I might just ask about two aspects of the backdrop in Washington. The proposed rule on outpatient hospital care has the elimination of potentially of the inpatient only rule. Can you just comment on what you think that might mean for your hospital and ASC business if that were to go through? And then just any updated figures on the public exchange volumes, how that contributed into the quarter, what you're seeing year to year? And do you have any updated thoughts on what the outlook for next year might be if the enhanced subsidies go away?

Hey, Ajay, it's Tom. So thanks for the questions. The first one, you know, obviously enabling additional innovation in the ASCs is positive for the USPI business. You know, I think about it this way, which is one is the reimbursement, allowable reimbursement, and certainly, you know, this move is positive. At the same time, you know, it takes work and experience and higher acuity ASC procedures to actually be able to successfully move those things from an inpatient setting to an outpatient setting. And as you know, the patient selection process criteria and expertise makes a big difference there so that you're doing the right things clinically. Those are all areas in which we're pretty advanced as an ASC operator and platform. So I think it plays to our advantages. I think it represents an opportunity for the future for sure. And I also think it gives us a platform to work with physicians to build the right protocols for many of these things to move into that more freestanding setting with the right patient selection. Sun, do you want to comment on the update on our exchange volumes? I would say just as a summary statement there, AJ, obviously the efforts to lobby for their extension and importantly the critical role they play in supporting small businesses and employees of small businesses in America is an added benefit of the exchanges that is obviously part of the discussion today.

Yeah, thank you, Tom. And just to add, you know, obviously healthcare exchange remains an important part of our business. For second quarter of 25, we saw about a 23% increase in admissions year over year. And we saw about a 28% increase in revenues from exchange year over year. In the second quarter, Our exchange volume now represents about 8% of our total admissions and about 7% of total consolidated tenant revenues.

Okay, thanks a lot.

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

Hi, thanks. I was wondering if you could just give some more specifics on the outperformance in the core results, and I'm specifically looking at the incremental 70 million on the USPI side, the increase in guidance. And then within that, is there anything Tenet has done specifically to improve your ability to sort of document, categorize patients as you submit claims? Are there new systems, new technologies, new vendors or partners, and obviously anything relating to AI? I'd be curious if there's new things that you're doing within there.

Hey, Josh. Well, kind of going backwards, USPI has its own significant revenue cycle capability. We think it's an industry-leading capability. It's an environment that mostly serves our own ASCs, but certainly serves ASCs beyond that. We're pretty busy in advancing a lot of those capabilities. I mean, it is not difficult for me to say that some of the improvement in our results over the last few years has been related to real standardization, technology deployment, better reporting, and certain advanced analytical tools that we have deployed in into the ASC environment. Not surprising, uh, given our focus in revenue cycle as a company that we have done that. And it's certainly paying dividends in terms of how we work in that environment, both on the retail collection side, as you can imagine, these are elective procedures, but also on the wholesale collection side, all the way from authorization, uh, back through document, accurate documentation and, um, more efficient management of the AR through technology and offshore capabilities. So we're really pleased with the platform that's being built for ASC revenue cycle within USPI. Son, do you want to comment on the nature of the guide?

Yeah, sure. Josh, in the first half and the second quarter, I think both consistent themes. We've seen high acuity, good case mix, good payer mix. good growth in some of our key case lines, service lines, including ortho and total joints. So all the trends that we've discussed previously, I think continue in USPI for second quarter. You know, that's why you saw the strong net revenue, overall growth of 7.7%, as well as a strong net revenue per case. So, and then I think good operating expense management, So we demonstrated 39.2% EBITDA margins in second quarter as well. So I think all those trends, you know, apply for both Q1 and Q2, which resulted in about a 50 million increase versus our prior guidance. And then, you know, our general expectations is for those trends to continue into the second half, which is part of the guidance raised for the remaining full year. I think, you know, we also remain positive on our M&A activity. In terms of contribution, as Sam noted in his opening statement, we expect to exceed our $250 million, you know, baseline assumption for USP M&A. So I think all those things contribute to the guidance raise. Thank you.

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

Hi, good morning. I just wanted to ask about the volumes. There's a little bit of a deceleration there in both the inpatient and adjusted admissions in the quarter. You took down the guidance by, I think, 50 basis points. Were volumes impacted by any discrete items in the quarter or anything else to kind of call out driving some of the deceleration for the quarter and the full year?

Thanks. Hey, well, first of all, I think the guidance is just simply reflecting the math that would play out for the rest of the year. No, it was a strong quarter. I mean, we had strong volumes, the right acuity and mix, and very much reflects the focus on our service lines as we have prioritized them. So I don't think there's anything particularly unusual other than seasonality.

All right. Thank you.

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

Hey, thanks for the question. Wanted to ask about payer contracting. There's a lot of different dynamics creating pressure on payers. Has there been any discernible shift in terms of your negotiations with payers? Are you still getting the normal updates you'd expect? And is there anything to report with respect to denial activity?

Yeah. Well, a couple of things. First of all, you know, obviously different parts of the sector at various times certainly go through their ups and downs. And, you know, I think our philosophy most importantly with the health plans, both the national plans and state-based plans, is to work consistently to create value in what we do in our level of, you our level of pricing and our negotiations, and also to create predictability for both sides over a multi-year period. I mean, I think that's ultimately what's probably most important on both sides so that each party can then manage their own operations. And we have extended that philosophy over the last few years into the next wave of contracts. I think most people were aware that there are a number of contracts that coming up and we're not seeing anything unusual and certainly no change in our guidance with respect to the way that we have been negotiating our contracts. But again, I think that's because, you know, we're committed to the value that we provide there, both from the standpoint of our highly efficient ambulatory business, but also working in an environment with reasonable and predictable rate increases so that we can focus on managing our own operations. Look, the denials activity, and it's really not just denial, it's kind of the disputes, documentation requests, denials, et cetera, have ramped up over the past few years post-COVID to levels that are, I would argue, not acceptable in some cases. And we have adapted, obviously this is part of Conifer's job, is to adapt and learn to respond to those things In the early days, the responses were driving up expenditures. Today, as we have evolved and realized this is a new normal, we have, of course, deployed more technology, more automation, trained up more offshore staff and other things to be able to respond to those types of requests and activities in a more efficient and, I would argue, more effective manner. We track things like our yield relative to the volume or dollars that were disputed or denied. And, you know, I think Conifer is doing well there for both ourselves and for our clients relative to the overall industry. You can see it in our results. And I think that translates across the board. And so, you know, this is a constant battle with respect to what's appropriate there. And obviously we welcome, you know, both regulation and other things that would support a reduction of some of that what we consider inappropriate activity. Got it. Thank you.

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

Thanks. Good morning. First, I just wanted to follow up on AJ's question. I do understand that the industry is lobbying for an extension of these subsidies and how important that could be to a lot of folks. But is there a framework that the company can share with us in terms of how to think about the potential impact to 2026 earnings if those subsidies do go away? And then sticking with that DC stuff, Maybe you can give us an update on the provider tax run rate you're seeing in 2025 versus I think the previous guidance was about 1.1 billion. And have you analyzed and have anything to share with us in terms of the impact of if the bill that just passed, it does get rolled out, what the impact to DPP could be over time as provider taxes? Thanks.

Yeah. Hey, Justin. So we don't have any comments about 2026 at this stage, and certainly all of the work and effort is focused on helping stakeholders realize, again, how important the exchanges are for families who utilize them, including those that came off of Medicaid from a Medicaid redetermination standpoint over the last few years. It's very much my belief that because of the existence of the exchanges and the subsidies for the people who don't have very high income levels, as Medicaid redetermination proceeded, the exchanges were a critical safety net for the individuals who needed health care insurance to have a landing spot. And it created what I consider a pretty smooth Medicaid redetermination process. because of the availability of those insurance options for individuals and families that needed it. And so that, in addition to the fact that, you know, the exchanges represent critical support for small businesses that are unable to provide broad-based insurance coverage options to their employees, which supports obviously a very large part of the economy, represents two of the most important prongs of the conversation around why it's important to extend these subsidies, not the least of which is that it affects red states more than blue states, given the nature of the administration and Congress today. That's also an important fact. So, look, I think the work is ongoing in that area. I think it's important, and I think it's important to more than just our industry. It affects other parts of our sector, but it also affects the macro economy through the support for small businesses, which helps to make them more competitive in the U.S. economy at large. The current situation and bill that passed, a lot of the impacts, as you know, have been pushed out pretty far into the very, very end of 27 or really 28. from that standpoint. And we really don't have any insight into how this will be implemented. There are new legislative proposals that have already come up attempting to rescind some parts of the OBBB, which are in play in Congress. And I think it just, you know, it remains an area of significant uncertainty. And we don't have any sort of projections to provide from that standpoint, especially because we're talking about, again, as I said, out to 2028. Son, do you want to cover? There was a question in there about the DPP programs.

Yeah, let me just clarify that, Justin. So for Q2 of 25, we recorded about $350 million of total Medicaid supplemental payments. So for the first half of this year, we're at about $675 million range. Now, we have pointed out some one-timers, so once you normalize for that in the first half of the year, our run rate for the full year is right around the 1.1, 1.2 billion range that we previously discussed.

Thanks.

Our next question comes from Sarah James with Cantor Fitzgerald. Please proceed with your question.

Thank you. I just wanted to circle back to what went on with the volume guide down. I understand seasonality and just the mass of the quarter impact on the year, but what actually changed in this quarter or in your view of the year? Are there certain segments or any types of deflation?

Well, the most important thing that we would be focused on that happened in the second quarter was, as I said earlier, the strength and success of our high acuity strategy that has been in place for multiple years, continuing to demonstrate in this market the ability to generate revenue and earnings across our hospital portfolio. I mean, that's really, at the end of the day, that's the most notable and important trend in the second quarter, which is that that strategy continues to deliver results.

Yes, thank you. Our next question comes from Steven Baxter with Wells Fargo. Please proceed with your question.

Yeah, hi, thanks. Just to follow up on Justin's question, we wanted to ask about the jump-off point for EBITDA this year. Is it as simple as, you know, removing the added period Medicaid supplemental EBITDA? I think it's $70 million, $79 million this quarter and $40 million with the first quarter. Or are there any other meaningful areas to consider, whether they're, you know, Medicaid supplemental payments or other sort of one-time contributors to the year that we should think about as we're bridging to 2026? Thank you.

We're not making any comments about 2026, nor are we commenting on headwinds and tailwinds yet for the following year.

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

Thank you very much. Just a quick follow-up on the acuity trends that you're seeing. Appreciate that the revenue per shows strong acuity trends there, and that's consistent with your strategy. but also just wanted to square that with the hospital inpatient surgeries being down. Just a little more detail on where you're seeing that stronger case mix and how that's kind of translating into the stronger rates on the hospital side. Thanks.

Yeah, I mean, our strength in cardiovascular, orthopedic, spine, neurosurgery, broad-based general surgery, robotics, I mean, those are all the areas that you know, we continue to focus on in terms of our work. Now, I would add to that emergency-driven trauma and trauma surgery. As you know, we have a lot of very large urban emergency departments that have built trauma capabilities in order to service patients in need of trauma. you know, as we have indicated over the past few years, our transfer strategy, always being willing to accept any patient from any outlying hospital, you know, as long as we have the services available to help them, we have been committed to providing that help. And obviously many of those patients tend to be sicker and may require more complex surgery. So all of those things have been contributors to the results from what we describe as a high acuity strategy.

Thank you.

Of course.

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

Yeah, thanks. Just one quick clarification. I was wondering if you could comment briefly on how much your medical case mix did increase in the quarter and if it changed much from prior trends. But my real question is looking at the EBITDA growth at USPI. Is there any way to quantify the contribution that you may still be seeing from continued synergies, whether from SED, Covenant? Just wondering if those are contributing to any of the growth still.

Thanks. Well, case mix acuity was up. I'm not sure exactly what you're asking, Sun. You may want to comment more specifically on that question. I mean, but... consistent with what we're saying about acuity, case mix index was up. That's referring to the hospital segment. On the USPI side, the revenue growth that we see, obviously in a very dynamic business, comes from all sorts of things, including same-store growth, volume growth, our payer contract annual escalators, rostering of new facilities onto our managed care contracts as part of our network strategy of having an alliance of high-quality, reliable centers. All of that contributes to the revenue growth, but that's why we provide the total revenue growth and also the same store revenue growth so that one can differentiate between those. And I think all of that data is consistent with, you know, both with success of the high acuity strategy, but also, you know, we're consistently performing in revenue growth above our long-term trend, which has been very positive for USPI.

Yeah, and Sam, just your, I'm sorry, Whit, your question on case mix. We're up about 1% year-over-year in Q2. And obviously, if you look at a longer period of time, that growth would be more significant based on acuity. Okay, thanks.

Our next question comes from Peter Chickering with Deutsche Bank. Please proceed with your question.

Hey, good morning, guys. Thanks for taking my questions. Nice quarter here. DSO has trended down nicely, maybe the lowest that I've ever seen with you guys. Can you talk about cash collections and what have you done differently or are the payers doing something differently? And from a cash flow perspective, should we continue with the models for the bulk of free cash flow going into repo with some M&A in there so you can buy back around 10 plus percent of your market cap each year while still delivering? Is that the right way to think about it?

Yes.

Well, okay. Just two separate things. Son, do you want to start with the second one and then we'll back into the revenue cycle question?

Yeah, sure. So Peter, yeah, we obviously have very strong free cash flow performance, have increased our guidance for free cash flow after NCI, you know, up $195 million. You know, I would say the other notable piece, obviously, is the amount of shared repurchases we completed in the second quarter of this year. It was an essential increase from our normal trends. You know, I would say looking forward, our capital allocation priorities haven't changed, right? USPI, M&A, hospital capex or high acuity strategy, and then maintaining our deleveraged balance sheet and a balance share purchase approach. It's hard to predict what our run rate share purchase activity will be in the next quarter, the second half of this year into 26. I think that'll depend on, you know, facts and circumstances. But, you know, I do believe our free cash flow and financial performance and balance sheet flexibility will afford us to make the right decisions as those things come.

Yeah, look, in summary on the first part of the question, as the industry has trended up overall in terms of denials and also the times to collect given some of the dispute and back and forth on documentation requests and other things, we've remained very focused on trying to keep that as tight as possible. using technology automation. I mean, one of the advantages that Conifer has is an incredibly standardized workflow that is really critical to not only collections but also timely collections in an environment where those timeframes have been increasing for a long period of time. We're obviously, as we've talked about before, supplementing some of those capabilities that we have today that used to be manual with AI-enabled technologies that allow us to produce more rapid, automated responses to various types of disputes based upon pattern recognition that you would see from various sources that allow us to do that more effectively. And that makes, in the end, what we're doing more reliable, but also, as you're pointing out, sort of faster. The other thing I would say about this environment in which we talk a lot about the dispute denial activity. And as I said earlier, I think some of it's highly inappropriate. But it's also important that we spend our time being committed to very accurate documentation and coding. And I think one of the things that Conifer does well is produce accurate documentation and coding. And that has a tendency to also reduce the dispute activity to some extent from the health plans, right? I mean, it is a two-way street in the end. And both parties have to perform in that direction. And that speeds up collections to some extent. So anyway, I said this earlier, and I'll let it be. Adapting to the current environment from a collection standpoint is a critical capability that we have developed. And that capability has moved from being manual when it first started to increase to much more technology-driven and workflow automation-driven.

Great. Thank you much.

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

Good morning. Thanks for the question here. Just as a follow-up on your ACA exchange volumes, With your reported hospital length of stay down probably 3% year over year and ACA exchange volumes up 28% during 2Q, is there any additional detail you can provide on procedural mix or length of stay across those exchange-based volumes? We've just been getting some comments from prominent payers in recent weeks regarding the elevated trend there across that group. So just curious if there are any particular areas that were contributors to that 2Q growth figure or if it was more broad-based across all specialties for your ACA exchange book. Thanks.

I don't think there's been anything unusual in this quarter versus prior quarters with respect to the exchange volumes. I mean, remember, the one thing I would say is the exchange business tends to behave similar to the Medicaid business more than the commercial business, in the sense that a disproportionately larger amount of it is emergency department driven. may still come with higher acuity, but it tends to be more emergency department driven. That's why the impact of the exchanges on our business is higher in the hospital segment versus the USPI segment, even though it's present in both. But I don't think that I noticed anything unusual about the nature of the exchange volumes this year, this quarter. Sun, is there anything you would point out there?

I think you're right, Tom. It's pretty consistent with prior mix overall. Okay.

Got it.

Thanks for coming.

Our next question comes from Ryan Langston with TD Cowan. Please proceed with your question.

Thanks. Good morning. SWB continues to run pretty favorably. I mean, I assume as you achieve these levels, this becomes kind of the new baseline for expectation to your operators. But I guess the question is how much more opportunity do you see on SWB and I guess what types of initiatives can you execute on to keep up sort of this level of performance?

Well, obviously effective labor management has been a strength of our organization, not just recently but over the last few years. we stay focused on the various parameters that drive demand, obviously length of stay, the acuity, the day-to-day productivity and accurate staffing needs that we have in our hospitals. But at the same time, from a supply standpoint, we've really, I think, benefited from improved recruiting strategies, relationships with some terrific nursing schools around the country where we've created good opportunities for their students and graduates to work in our environments, and also improving our retention rates as a result of what we've done. We found that making investments, and we have made real investments, in our nursing and overall hospital management director and other supervisor levels with special recognitions and other things that have been ongoing for multiple years because we see the value that they provide in terms of creating a stable and effective workforce for patient care. That has been an important part of what we have done over the last few years and recognizing their efforts. So, I mean, I think, look, all of those things are sustainable strategies, and all of them contribute to the improvements that we've made, both in our efficiencies and effectiveness there.

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

Hey, good morning. I'm going to ask Tom a question he's not going to answer. When he doesn't answer it, I'm going to ask him another question. Do you think that now that we've gotten the bill behind us and we know the no's, is the environment, if you were able to sell any more hospitals, is the environment stable as such that that's more possible now?

You know, John, I'm not sure how to answer that question. We don't comment on asset sales anything that we may be looking at there. We're pretty happy with the portfolio. It's obviously performing based upon the last couple of years in the post-transaction environment. I don't know how to comment on whether the broader industry has fully understood the implications for them of the of the OBBB or anything else that may come, you know, I would take this opportunity to reiterate that our view from what we have seen so far in the external landscape related to legislation, regulation, et cetera, Washington, essentially, you know, we think about this pretty carefully. It has not changed our commitment to our core strategy as it stands right now. And so I feel good about that. looking forward.

Yeah, so you let me write to my other question. Now that this bill is behind us, what are your current legislative and lobbying priorities in D.C.? And where are you going to spend your time there?

The most important area right now, as I said, both for the healthcare industry, for the insurance industry, and importantly, we think Now that we have an understanding of how important these exchanges are for small businesses and keeping and remaining a competitive workforce for small businesses in America is engaging in dialogue about mechanisms to extend the exchange subsidies.

Our final question comes from Kevin Fishbeck with Bank of America. Please proceed with your question.

All right, great. Thanks. I guess I wanted to understand a little bit more of the commentary on hospital volumes and the payer mix. I guess how much of the payer mix improvement that you're seeing is because of the exchange growth? If we took exchanges out, would you still be talking about improved payer mix to the same degree? And then When we think about the volume outlook, the volume outlook being lower, you guys have always had a different view on volume, so it's hard to kind of tell how much is this high acuity strategy versus underlying demand. Do you have a sense of what underlying demand growth was in the quarter? Was it consistent with where Q1 was, or did it decelerate kind of similar to how your overall volume has decelerated from Q1 to Q2? Thanks.

Yeah, a couple things. One is commercial growth. commercial mix was strong. And as I indicated earlier, maybe another way of describing that, I mean, obviously the growth that Sun described in the exchanges indicates that some of that mixed strength is definitely, on the payer mix side, is definitely coming from the exchanges. And this is, again, going back to the importance of the exchanges as a landing spot as Medicaid redetermination has worked its way through the through the overall system, it's been an important landing spot. And then finally, no, I mean, I think, look, underlying demand in this environment is still strong on a macro basis. I mean, it wouldn't be the case that we would be able to lose significant amounts of underlying what you would call general med-surg, emergency department, et cetera, demand in exists solely on a high acuity strategy, right? The high acuity strategy is meant to support the types of margin expansion and growth that we have seen on an efficient basis in the hospital segment. And the margin expansion in the hospital segment over the last 12, I mean, we were just looking over the last 12 months or even over the last three to four years has been significant. And that's really what the strategy has helped support But I don't think it's worth making anything of one single quarter, especially when you have seasonal trends and quarter to quarter trends and ramp on and ramp off of respiratory illness and other things. I think this will play itself out over time. The underlying demand environment, when you compare it to a multi-year basis, still seems strong to me. Okay, great. Thanks.

We have reached the end of the question and answer session, and this concludes today's conference. You may disconnect your lines at this time, and we thank you for your participation.