Universal Health Services, Inc.

Good day and thank you for standing by. Welcome to the fourth quarter 2024 Universal Health Services Earnings Conference call. At this time, all participants are on a listen-only mode. After the speaker's presentation, there will be a question and answer session. To ask a question during the session, you need to press star 1-1 on your telephone. You will then hear an automated message advising your hand is raised. To withdraw your question, please press star 1-1 again. Please be advised, today's conference is being recorded. I would now like to hand the conference over to your speaker today, Steve Filton, Executive Vice President, and CFO, please go ahead.

Thank you, and good morning. Mark Miller is also joining us this morning. We welcome you to this review of Universal Health Services results for the fourth quarter ended December 31, 2024. During the conference call, we'll be using words such as believes, expects, anticipates, estimates, and similar words that represent forecast projections and forward-looking statements. For anyone not familiar with the risks and uncertainties inherent in these forward-looking statements, I recommend a careful reading of the section on risk factors and forward-looking statements on risk factors in our Form 10-K for the year ended December 31, 2024. We'd like to highlight certain developments and business trends before opening the call up to questions. As discussed in our press release last night, the company reported net income attributable to UHS for diluted share of $4.96 for the fourth quarter of 2024. After adjusting for the impact of the items requested in the supplemental schedule included with the press release, our adjusted net income attributable to UHS for diluted share was $4.92 for the quarter ended December 31, 2024.

During the fourth quarter of 2024, on the same facility basis, adjusted admissions to our acute care hospitals increased 2.2% over fourth quarter of prior year. same facility net revenues in our acute care hospital segment increased by 8.7% during the fourth quarter of 2024 as compared to last year's fourth quarter, driven primarily by a 5.3% increase in net revenue per adjusted admission. Meanwhile, operating expenses continue to be well managed. The amount of premium pay in the quarter, for example, which declined from a peak of 153 million for the first quarter of 2022, was 60 million in the fourth quarter of 2024, remaining consistent with the previous two quarters. For the full year of 2024, our strong acute care revenues, combined with effective expense controls, resulted in a 13% increase in EBITDA, even after excluding the growth in Medicaid supplemental payments. During the fourth quarter, same facility revenues at our behavioral health hospitals increased by 11.1%, driven primarily by an 8.7% increase in revenue per adjusted patient day. Excluding the year-over-year growth in Medicaid supplemental payments, the same facility revenue increased with 7.4%.

Included in our operating results during the fourth quarter of 2024 were aggregate net incremental reimbursements of approximately $50 million recorded in connection with various state supplemental Medicaid programs, including $31 million of additional net reimbursements from the Nevada State Directed Payment Program covering the six-month period of July 1, 2024 through December 31, 2024. These net reimbursements were more than the supplemental program projections included in our earnings guidance for the full year of 2024 as revised on July 24th, 2024. As a result of unfavorable trends experienced during the past several years during the fourth quarter of 2024, we recorded a $35 million increase to our reserves for self-insured professional and general liability claims. Our operating results for the full year of 2024 included a $79 million increase to our self-insured professional and liability reserves. Our cash generated from operating activities was $658 million during the fourth quarter of 2024 as compared to $452 million during the same quarter in 2023, and $2.067 billion during the full year of 2024 as compared to $1.268 billion during 2023. We spent $944 million on capital expenditures during 2024, which was consistent with our original forecast for the year. In our acute division, we opened West Henderson Hospital in Las Vegas late in 2024 and plan to open Cedar Hill Medical Center in Washington, D.C. in the next few months. We forecast that these facilities will be EBITDA positive in 2025 on a combined basis. In both of our segments, we continue to invest in expansion of our outpatient presence and the broadening of our continuum of care. For the full year of 2024, we acquired $599 million of our own shares pursuant to our share repurchase program. Since January 1 of 2019, we have repurchased more than 29.2 million shares, representing approximately 32% of our shares outstanding as of that date. As of December 31, 2024, we had $1.17 billion of aggregate available borrowing capacity pursuant to our $1.3 billion revolving credit facility.

The core operating assumptions underlying our 2025 operating results forecast, which was provided in last night's release, largely reflect the historical trends in the respective businesses with EBITDA growth in the mid single digits. We expect continued improvement in salary and wages and general cost trends that will remain largely stable in 2025. As noted in our 10-K filed yesterday, our 2025 operating results forecast excludes any supplemental Medicaid revenues in Tennessee and the District of Columbia, pending CMS's approval of those programs. As the 10K schedule reflects, our 2025 forecast assumes total consolidated Medicaid supplemental payments will decrease slightly as compared to 2024. We believe demand for our behavioral services remains solid, and our same facility adjusted patient day growth in 2025 at our facilities located in the U.S. is forecasted to be in the 2.5 to 3% range. We've accelerated technology investments in our behavioral hospitals to improve patient care, including electronic health record implementations and expanded use of patient monitoring automation. We acknowledge that the current political environment has created a level of uncertainty, especially as it relates to ongoing Medicaid reimbursement. Our 2025 forecast is based on current Medicaid reimbursement projections in connection with various programs that could be subject to change. In our acute business segment, we are pleased that 80% of our hospitals currently have an A or B wheat frog rating, well above the national average. And in our behavioral division, we saw meaningfully significant improvement in patient experience scores in 2024. We are focusing on continued improvement of these metrics in 2025. We are now pleased to answer your questions.

Thank you, ladies and gentlemen. If you have a question or a comment at this time, please press star 1-1 on your telephone. If your question has been answered or you were to move yourself from the queue, please press star 1-1 again. We will pause for a moment while we compile our Q&A roster. Our first question comes from Andrew Mock with Barclays. Your line is open.

Hi, good morning. The 2025 EBITDA guidance is up 5% to 11%, which is higher than typical growth rates despite state supplemental payments forecasted to be down year over year. So I'd love to hear a little bit more color on what's driving the higher underlying growth in 2025. Thanks.

Sure, Andrew. Well, I think it's a couple of things. I mean, number one, you know, just the core growth, core EBITDA growth that Mark talked about in the two segments, I think is being driven by a return, as he described, to sort of historical norms, solid volume growth, pretty robust pricing, and I think, you know, very effective expense control. And, you know, I think we don't have the pressures on our operating expenses that, you know, were such a drag during the COVID years, the wage inflation, the very high use of premium pay, not necessarily related to COVID, but on the acute side, the professional fee expense pressures that we faced in 2023, et cetera. So I think as our commentary reflected in our prepared comments, that we're expecting a much more sort of stable operating environment outside of potentially the reimbursement changes that are being discussed at a pretty high level. In addition to that, as I think our comments indicated, we incurred a significant amount of incremental malpractice expense in 2024 that we are hoping will not recur in 2025. And so that's another source of upside in the earnings. And I know you're really talking about operating earnings, but from an EPS perspective, we then get a boost from a reduction in interest rates or interest expense as well as, you know, continued reduction in our share count.

Great. And then maybe just to follow up, the guidance range, I think, is $127 million wide, which is higher than previous years despite better operations and visibility. So why is the range of outcomes here wider than usual? And, you know, where are the puts and takes within that range? Thanks.

Yeah, I mean, I think, and I think, you know, Mark commented on this in the prepared remarks, and we acknowledge that... The items that are sort of beyond our control, you know, in terms of government reimbursement and potential changes in that regard, you know, we've tried to provide some level of caution and conservatism in the guidance, and I think part of that is the wider range that we've provided.

Great. Thank you. One moment for our next question. Our next question comes from Ben Hendricks with RBC Capital Markets. Your line is open.

Hey, great. Thank you very much. Just wanted to go back to the slight decrease in DPP that you're foreseeing for next year. Is there any way to parse out how much of that is just overall conservatism versus foreseeable changes in specific programs?

Ben, I think the main reason for the decline is as we've disclosed in each quarter, you know, during 2024, we've recognized some changes DPP payments that were related to prior periods. And I think that's the main reason for the decline is that some of the DPP payments and DPP revenues that we recognized in 2024 really related to prior periods. There may be some programs that had small declines next year, but I think that's the main reason driving the declines.

Thanks, and then just to follow up on the malpractice reserves, just how are you thinking overall about adequacy at this point? Are we at a point where there is a reasonable cushion, or are there trends that you're seeing now that could increase the probability of another adjustment this year?

Thanks. Yeah, so I think it's worth noting that in establishing our malpractice reserves, we use a third-party actuary who evaluates our claims history, pending claims, industry trends, etc. You know, it's a relatively comprehensive analysis. Historically, we've tried to set and establish our reserves sort of at the midpoint of the range that our third-party actuary provides to us. Given some of the volatility in that area and some of the pressure, we tried this year to move a little bit towards the higher end of the range. So we are hoping that there's an element of conservatism built into those reserves and that there won't be a need for another uptick in 2025. Obviously, we can't be assured of that, but we feel like we've taken a pretty prudent position here. Thank you.

One moment for our next question. Our next question comes from Anne Hines with NSUHO. Your line is open.

Hi, good morning. Thank you. Can we talk about behavioral things for patient days? I remember thinking, and maybe I'm remembering incorrectly, that you thought you would be exiting 2024 at about 3%, which I believe it was below 2%. So what was the driver of that? And I think you said in guidance you assume it's going to accelerate to 2.5% to 3%. Can you just tell us what the drivers of that acceleration is?

Yeah. So, and in fact, Ann, I think for the first two-thirds of the quarter, October, November, we were tracking sort of in that 2.5% range and, you know, felt pretty good about things. You know, I remember, and honestly, probably my last public appearance was at your conference in early December, and I remember telling people, that I thought we were doing well, except, you know, it was always hard to predict what would happen in the back half of December with the holidays. That's always sort of unpredictable. And in fact, we did see a fairly dramatic decline in our patient day volumes in behavioral in the back half of December. I think having the Christmas and New Year's holidays right in the middle of the week on a Wednesday really sort of made those last two weeks, particularly for that child and adolescent population, you know, a much softer result than we were anticipating, and quite frankly, we've experienced historically. Volumes tended to sort of rebound in early January, which led us to believe that, you know, that was really kind of a temporary transient sort of thing. We've struggled a little bit over the last month, mainly because of difficult winter weather around the country, particularly in places that quite frankly are not, you know, generally used to or equipped for winter weather. You know, we've seen school closures in a pretty large scale in places like Virginia and Tennessee and Kentucky and Mississippi, places that don't, you know, generally close schools in the wintertime. But again, I think we feel that those are transient sorts of dynamics and that for the full year, you know, getting to that two and a half, three percent patient day growth, you know, should not be sort of a heroic metric to achieve.

Great. And then staying on the behavioral theme, Medicaid rates have been good for Universal in the industry. Can you remind us what they actually were in 2024 and what you expect in 2025? Yeah.

I mean, so what's built into our guidance for 2025 is, I would say, same-store behavioral revenue growth in the you know, 6%, 7%, 8% range. And, again, I think that's sort of 2.5% to 3% volume and 3% to 4% price. To be fair, that 3% to 4% price is exclusive of any changes in supplemental payments. You know, that's just what I would describe as core pricing. Our core pricing, and I think that's sort of the crux of your question, has generally been better than that over the last several years and will continue to press our payers. and hope to do better than that. So if there's an element of conservatism in our behavioral projections, it's probably on the pricing side of the equation.

Great. Thank you.

One moment for our next question. Our next question comes from Justin Lake with Wolf Research. Your line is open.

Thanks. Good morning. I wanted to move over to the policy stuff. Specifically, looks like the bigger ticket items like caps are off the table on Medicaid. Some discussion that maybe provider taxes would be a place they would pivot to. I know you've

sophisticated on this stuff what are you hearing there in terms of of the you know the appetite to look at provider taxes as an area of savings within this legislation yeah so Justin I would say and I think you know this I mean I think the administration has really made no sort of definitive public statements about provider taxes The point that we've made and I think our peer companies have made is there appears to be wide support for these provider tax or directed payment programs around the country in a large number of states, including states of all political stripes. I think one of the things that we're learning or observing from this debate within Congress over the budget bill is that There is a fair amount of support, again, I think throughout the country for Medicaid programs and protecting Medicaid programs. There hasn't been a whole lot of discussion specifically about directed payment programs, but we believe that there's a significant amount of political support at the state level for those programs in a great many states.

And I just want to add to what Steve just said there, because we're clearly monitoring this very closely, talking off the record with many of the folks, not just in Washington, but in the states. And I think that's a key point. The folks in Congress are hearing from the governor's offices in many of these states. And like Steve said, it's a bipartisan effort. It's not just the Democratic states, but it's many of the large Republican-led states as well. So that tends to suggest that the pushback is significant, and I think we're in a better position than sometimes what we see on the news.

Great. And then just another question on DPP. I know you've got some dollars potentially coming in D.C. and Tennessee. You guys do a great job of giving color on that in your 10K. It looks like you're not projecting that. Anything to read into that for 2025? Any change in your level of confidence that this stuff comes through at the end of the day?

We believe that our 2025 forecast reflects our historical practices when it comes to DPP, and that is once a program has been approved and is in place, even though all these programs have to be renewed and reapproved annually, we presume that programs that have been approved historically will continue to be approved and they remain in our guide. The two programs you referenced, Tennessee and Washington, D.C., are new programs that have only been partially approved. So for instance, Tennessee, the actual program has been approved and the dollars have been approved for the back half of 2024, but it still requires CMS approval of the 1115 Medicaid waiver. And so until full approval is granted, we haven't included any of those Tennessee dollars. The DC approval is pending in its entirety. We haven't included any of those dollars either in Q4 or in our 2025 guidance. In both cases, the state or the district hospital associations tell us and tell their constituents that they've not heard anything from CMS suggesting that the programs are problematic in any way in their structure. They expect them to be approved. There's some uncertainty with the timing of that. But yeah, I mean, I will tell you the expectation of the hospital associations themselves is that approvals are pending and have just sort of been slowed by the transition of administrations. We'll see. But again, nothing to be read into how we've handled it other than in our minds consistent with the way we've handled these DPP programs from the beginning.

Thanks. Appreciate all the color.

One moment for our next question. Our next question comes from Peter Chickering with Deutsche Bank. Your line is open.

Hey, good morning guys. Thanks for taking my questions. Leverage is now below sort of two times here. Can you just remind us what your targeted leverage ratios are here? And today, you know, using all of your free cash flow to do share repurchases. At what point do you start borrowing to maintain your leverage ratios and using those borrowings to increase your share repurchases?

Thanks, Pito. So, You know, I think we have historically operated at a leverage level, you know, generally in sort of the high twos approaching three. We're certainly comfortable at a level like that. And I would think that, you know, that's, you know, where we would generally target things in the future. I think, you know, our guidance for the year presumes that, you know, we'll use the bulk of our free cash flow for share repurchase, the possibility that we could lever up and use even more than that, I think is certainly a real possibility and not something we've decided today. But again, in our guidance, I think we were reasonably conservative in thinking that our share repurchase levels would be around what they've been the last several years in that sort of 600 to 800 million dollar range.

Okay, but so intellectually, we could be thinking about you guys start actually using leverage here to at least maintaining some leverage above where it is today if you feel comfortable with the macro level to start increasing beyond just free cash flow.

No, I think that's fair. And I think that, you know, if you look at our historical practices, there certainly have been times where we have done that, for sure.

Okay, fair enough. And then on behavioral, you know, like you guys closed three hospitals this quarter. You know, has it impacted, you know, like your EBITDA when you – close those facilities? You know, how many other facilities do you look at for portfolio trimmings or in 2025? And, you know, with such a larger, you know, supply, demand, and balance in behavioral, I guess, you know, why is there a need to close any of these facilities? Thank you.

Yeah, I think if someone wanted to take the time and, for instance, take a look at our portfolio of behavioral facilities, let's say 10 years ago and where we are today, you know, I think that you would find that portfolio rationalization is sort of an ongoing part of our behavioral strategy and that the portfolio of hospitals that we have today is different than it was 10 years ago. We have sold some facilities. We've consolidated a number of facilities. We've sort of retooled facilities to provide different services. We've done any number of things. It's a large portfolio and generally an individual hospital is not material with the portfolio, so we don't necessarily disclose or discuss in detail when we do these things. But it's really that aspect of it. And when you ask sort of what's the rationale for that or what causes that, while we acknowledge or we would agree with your overall comment that I think behavioral demand has been strong during this period, obviously demand for particular services in a particular area particular reimbursement dynamics, all those things can change in the interim. And, you know, we do react to those things and, you know, effectively, you know, try and look at those facilities that are sort of least efficient, you know, lesser returning and, you know, trying to determine whether they have kind of a path to getting, you know, sort of more towards the bell curve of performance. And if they don't, you know, we look for, you know, potential exit strategies, which again, could be closure, could be sale, could be consolidation, could be retooling. All those things I think are always on the table.

Great. Thanks so much, guys, and nice job.

One moment for our next question. Our next question comes from Joanna Gottschalk with Bank of America. Your line is open.

Hi, good morning. Thanks so much for taking the questions. So this first, because I don't know if they're admitted, but yeah, thanks for talking about your assumptions for your behavioral segment growth for 25, but what do you assume for acute revenue growth volumes versus pricing?

Yeah, so I think the assumptions for the acute division are also, you know, mid-single-digit revenue growth, probably a little bit more modest, you know, maybe in the 5%, 6% range. And I would say split pretty evenly between price and volume. So the two and a half, 3% adjusted admission growth, two and a half, 3% pricing growth. And again, I think in both segments, in this environment where expenses have, you know, moderated wage inflation is moderated, the use of premium pay is moderated, position expenses are moderated, that, you know, mid single digit revenue growth in both divisions in our mind should be sufficient to allow us to grow EBITDA and expand margins.

Thanks for that. And I guess on wages, because I think the nationwide data on wage growth for nursing kind of showed some acceleration in the late 2024. Are you seeing that or is it just a function of some comp issue there? john i'm sorry when you said that the national data is showing what i didn't hear increase increase in wages the wages yeah where is that acceleration slightly nothing material obviously but like just kind of versus you know the the earlier in 24 and then like somehow the couple of these last months in 24 kind of showed you know a little bit higher glory over here so i don't know if you see any of that i mean sounds like he's thinking about you know kind of moderation in wage inflation for 25, but I just want to ask if there was anything that happened in late 24 that, you know, kind of might have changed that view a little bit.

Yeah, so again, you know, clearly we've seen a moderation in wage inflation coming out of the pandemic over the last couple of years, and I would sort of characterize the wage environment as fairly stable. You know, I apologize I didn't hear you the first time, but I think, you know, like you said, those The national survey sort of suggests kind of some incremental pressure on wages. I don't think we're really seeing that. It doesn't mean that we won't, but it doesn't feel like there's that sort of comprehensive pressure and real significant pressure on wages that we were seeing a couple years ago. It feels like the wage environment and basically the supply-demand environment for labor has stabilized pretty significantly.

And as we lessen our dependence on temporary labor, our wages are overall, you know, continue to go down.

Exactly. Thanks. And if I may just squeeze in a last follow up on the DPP discussion and how you assume 25 down versus 24. So two items there, right? Can you quantify how much was prior period that you record in 24? And also, because you also said there are some problems that expect that you expect to decline. So is it based in those in those states, particularly those programs are based on enrollment. And that's what's happening in some of these states going to have a lower VPP dollars available to them because it's linked to enrollment. Thank you.

Yeah, so, you know, I think if you go back and you look at our transcripts from the first three quarters, you know, in each quarter, we called out how much prior period there might have been. And it strikes me that it was a roughly sort of 15, $20 million a quarter. So you can extrapolate that and it's, you know, maybe 60, $80 million of non-recurring or out of period items that we had in 2024. And as I said to, you know, kind of a previous question, I think that's the main driver. There may be some individual programs that are showing sort of slight declines next year. But for the most part, once programs have been established, our historical sort of experiences, they stay at or, you know, if anything, they sort of grow. So, again, I don't think that the slight decline in DDP for next year that we're forecasting is – is mostly driven by the out-of-period stuff we had in 2024 rather than any real declines in the programs in 2025.

Thanks for that clarification. I appreciate it. Thank you.

One moment for our next question. Our next question comes from Stephen Baxter with Wells Fargo. Your line is open.

Hi, thanks. Just two quick ones. I was hoping the first, just in case I might have missed it, but sizing the full year amount that the medical malpractice expense came in above your initial plan and how much of that you assume normalizes and becomes a tailwind to the year-over-year EBITDA growth. And then just another follow-up on the DPP discussion. I understand fully you're not including 2025 amounts for Tennessee or for Washington, D.C. at this point, pending approval, but how do we think about, you know, what percentage of this, you know, DPP contribution that's in the guidance still for this year is tied to programs that do need to be renewed at some point this year, so might only have partial year coverage, you know, kind of as exists today? Thank you.

Yeah, so as far as malpractice goes, you know, what we said in our prepared remarks was we had $79 million of additional malpractice reserves that we added or recorded, you know, above and beyond what we had in our original guidance. And for the most part, I think, you know, we don't believe that those expenses recur. And so that, you know, contributes to some of the growth that we have in 2025. You know, we think we've been reasonably conservative. To be fair, that's a volatile area. that can change and does change, but we feel like we've been fairly prudent and fairly conservative in general. As far as your DPP question, I think as the previous questioner indicated, we have a significant amount of disclosure about our DPP programs by state, and I'd refer everyone, I know we filed the 10-K last night, so I'm sure people have had a chance to review it in detail, but we literally go through each program you know, indicate what's been approved, what's not been approved. I mean, my guesstimate, you know, is that probably half of the DPP monies in our forecast roughly have been approved for next year already, and probably half have, you know, approvals still pending.

Thank you. One moment for our next question. Our next question comes from Sarah James with Cantor Fitzgerald. Your line is open.

Thank you. I wanted to go back to your strategy around the behavioral portfolio. Can you talk a little bit about areas that you're looking to expand? Are you guys looking at CTC or methadone clinics? Are you looking at more outpatient? Or is it really still focused on inpatient?

Yeah, I think we've said in previous calls, Sarah, and I think this is true really of both segments, but specific to the behavioral business, I think we're looking to build out our continuum of care, and I think either Mark or I mentioned that in our prepared remarks, which I think in behavioral specifically means building out the outpatient continuum. And I think that's reflective of historically building out the outpatient continuum generally meant on our campuses and sort of related to our inpatient programs. So patients who were discharged as inpatients often require continued follow-up care and often receive that care in our intensive outpatient or partial hospitalization programs. I think we've started to develop more of a presence in freestanding outpatient facilities around the country. We acknowledge that some people who are receiving outpatient care don't necessarily feel comfortable receiving it on the campus of an inpatient hospital or affiliated with an inpatient hospital. And so we're finding that there is demand for freestanding outpatient care separate and apart from our hospitals. We continue to build out our outpatient capabilities as it relates to both active military and retired military. We have a real specialization in that. We have begun, and again, I think we've talked about this in previous calls, to establish a little bit more of a presence in the opioid disorder space. I think we are tending to do so, again, more as sort of part of a broader continuum of care rather than just sort of flat out medically assisted treatment facilities that are just dispensing medication. You know, I think we feel like given our presence, you know, in such a broad continuum, you know, real ability to provide a competitive or, you know, clinical advantage is being able to provide patients with sort of a whole continuum of care, not just medically assisted treatment, whether that's methadone or Suboxone or whatever, but, you know, outpatient treatment, et cetera, inpatient treatment if that's required, et cetera. And so to the degree that we're entering or expanding our presence in that opioid space, I think it'll be in that context of integrating with our broader continuum of care.

Great. And can you give us an idea of timeline to materiality of that? So what does the pipeline look like or how fast do you expect those businesses to grow?

Yeah, I mean, so again, I would make the point that we have a significant outpatient presence currently, mostly associated with our hospitals and on our hospital campuses. Um, the, the freestanding sort of efforts, I think, you know, reasonably, um, you know, could result in probably, you know, 10 or so or a dozen or so additional facilities, uh, each year. The OUD space requires, um, a bit more of a development pipeline. So I think a little bit harder to, to project that. But again, the point that I make there is, um, I think that's likely to be, you know, um, integrated with, uh, some of our existing continuums. but a little bit harder to predict and a little bit slower to ram.

Thank you.

One moment for our next question. Our next question comes from AJ Rice with UBS. Your line is open.

Hi, everybody. I appreciate, Steve, that you guys are really the only one that's made comments about... what it might mean if the exchange enhanced subsidies were to go away in 26. I think you put about a $50 million headwind on that. Can you just, since you're the only one that's really done that, can you just flesh out some of the key assumptions you've got in coming up with that number and how much variability you think there might be around that? Or is that, you know, you have a pretty good target on that?

Yeah, so we made those comments, or I made those comments back in the fall. And honestly, AJ, I made them because I think people were generally overestimating the impact that we might have if the subsidies, the exchange subsidies were to go away, which I don't believe is a certainty in any event at the moment. And I made the point when we floated that estimate that it was very much a guesstimate. It's really based on some pretty high-level assumptions. About 5% of our acute admissions are exchange-covered patients right now. We assumed that about half of those folks would lose their coverage if the subsidies went away. Now, again, there's a lot of nuances that go along with that. Some might be able to get other coverage. Some might qualify for Medicaid in certain states, et cetera. But we assumed about half those folks would lose their coverage. we would lose the elected business that those folks were bringing to our hospitals now, and we presume they would still come to our hospitals for their emergency coverage, and obviously we wouldn't be reimbursed for that. And so that's kind of the basis of the assumptions that we made. The other point I think that we made is this is, I think, largely an acute care dynamic. We don't separately track the number of exchange patients we have on the behavioral side in large part because we don't think it's quite as significant. And I think that's historically been because so many of these exchange products have very high copays and deductibles that are often not relevant to providing coverage in a behavioral hospital where they're likely to incur a much smaller bill than they would in acute hospitals.

Okay. All right. Thanks for that. I just want to ask, Maybe two aspects of the guidance. I want to see if they're reflected in there. I think you've got some insurance revenue step up in 25. Can you just comment on that? And is that a top line dynamic that doesn't affect the operating income and so on? And then the second thing I was going to ask about in the guidance is you opened West Henderson in Las Vegas late last year. You've got, I believe, a DC hospital that you're opening this spring. Do you think those are going to have much impact on consolidated revenue and EBITDA? And how about on the same store numbers, because those are two big markets. Do they draw away from your existing facilities enough to impact the same store trends?

Yeah, so as far as your first question about insurance revenue, a number of people, I think, sort of noted that the Revenue guidance that we issued last night is sort of above the mid-single digits that I've talked about on this call. And I think your question addresses that. There's probably an assumption of about a $200 million increase in the revenues at our insurance subsidiary. So that affects that top line, as we sort of discussed historically, our insurance subsidiary tends to operate at something pretty close to break even. It's reflective on the revenue line, but not really reflective in a significant way. As far as your second question about the two hospital openings, we mentioned in our prepared remarks that we expect that the combination of West Henderson in Vegas and Cedar Hill in Washington, D.C. will be EBITDA positive. It will note, and this will be a cosmetic thing, that as we look at same store, admissions and same-store revenues and even same-store earnings, that'll be a little bit, I think, distorting in our next year's numbers because both of those facilities are opening in markets where we have an existing presence. And so there'll probably be some cannibalization of our existing business. So I think it will make our same-store numbers look a little bit depressed, particularly admission numbers. But I think overall... Wes Henderson has gotten off to a very fast start, as has been our experience when we open hospitals in Las Vegas. We're expecting Cedar Hill to get off to a solid start as well. So Cedar Hospital should be much of a drag on earnings in 2025. Okay.

All right. Thanks a lot. One moment for our next question. Our next question comes from Michael Ha with Bayer. Your line is open.

All right, thank you. Two quick ones to start. Just to confirm on DPP for Tennessee and D.C., is the total current, I guess, payment upside $169 million across those two? And what do you typically recognize in terms of the flow-through down into earnings on DPP?

Yeah, so, Michael, I don't have our 10-K right in front of us, but that number sounds... reasonably close, but people can validate that we disclose the numbers on both our expected benefit from both those programs in the 10-K. And as to your second question, you know, we generally, you know, have the view because we disclose our, all of our DPP numbers disclosed are net numbers, that is net of the provider tax. So we assume those numbers, you know, generally drop to the bottom line. Obviously, we make the point all the time that those reimbursements are really meant to provide for, frankly, what's been inadequate Medicaid reimbursement for many years. So, you know, the immediate impact is a significant boost to our earnings, but it's really making up in our minds for, you know, deficient earnings in the past.

Got it. Thank you. And then maybe a quick one and then Another longer one. For flu season, I haven't heard you mention it. We're seeing one of the strongest in recent history. Any impact on 1Q? And then my real question would be, just to return to historical margins, you're there on behavioral a lot quicker than I think everyone expected. Looks like acute margins is really the next phase, and the embedded margin improvement seems quite powerful. I guess at this kind of pace of margin improvement over the past year, would it be fair to say you might only be about a year or two away from getting back to those pre-COVID levels? And then what does that path look like? What needs to happen operationally for that to materialize? Is it more like a return to normative patient mix levels or other efforts, initiatives, and flight? Any comments here would be great. Thank you.

So as to your question about the flu season, I think what we found is the flu season, which started earlier than usual for us in 2024, excuse me, in 2023, started later in 2024, although seemed to be more intense once it got going. Overall, I think when we look at our respiratory cases for the fourth quarter, not altogether different in 2024 than they were in 2023. To your point, I think the flu season and busy flu season has continued into the first quarter. I think, you know, generally we always have the view that A busy flu season, or frankly not a busy flu season, tends not to have a really significant impact on earnings. Flu and respiratory cases tend to not be the most profitable cases that we have. So overall, I think when we look back on annual results, we tend not to, I think, cite a busy flu season or a non-busy flu season as something that moves the needle in a significant way, although we acknowledge that volumes have been impacted, particularly will be impacted in Q1 by the busy flu season. As far as your margin question goes, I think mainly directed towards the acute hospitals. We've mentioned before, I think, that there are some structural hurdles that make it difficult for the acute business to necessarily return to pre-COVID margins. Things like the significant increase, like 150 basis point increase in physician expenses that we experienced mostly in 2023, the continued shift of profitable procedural and surgical business from inpatient to outpatient. But generally, you know, our margins have been improving in that business. And I think we'll continue to improve, like you said, over the next couple of years, whether or not during that period we can get all the way back to pre-COVID margins. I'm not sure or I'm not certain about that. I think, to your point, we've gotten there on the behavioral side. I think we'll continue to grow those. And so as a result, I think we will get back to consolidated pre-COVID margins over the course of the next couple of years.

Thank you. One moment for our next question. Our next question comes from Benjamin Rossi with JP Morgan. Your line is open.

Hi. Thanks for the question. Just on premium pay, you mentioned premium pay at about $60 million coming in flat quarter over quarter versus your previous goal of exiting the year at about $50 million a quarter. Is that more opportunistic usage to manage throughput during 4Q? And then with the Q volumes coming down, you know, moderating a bit for 2025, where do you see premium pay leveling out in this coming year?

I think one of the challenges in terms of further reductions to premium pay is that one of the things that occurred during COVID was more and more nurses chose to work as temporary or traveling nurses, preferring the flexibility that came with those jobs. And some of those nurses have returned to full-time work in our hospitals. We'll certainly try and attract more, but I do think there has been kind of that structural shift, and there are just more nurses who are wanting to and willing to work as temporary and traveling nurses. So I think realistically, you know, we made the comment in, you know, in our prepared remarks that we've run at about that $60 million a quarter premium pay for the last three quarters. You know, might we be able to tweak that a little bit lower? Sure. But I don't see really significant savings from driving that number a whole lot lower than where it is today.

Great. Thanks for the cover there. And then just to follow up, I know it's early here, but I had some conversation on tariffs and proposed reciprocal tariffs. Just curious how you're thinking about the potential impact of supply spend and maybe where your fixed pricing stands for your 2025 supply spend or where you have any other pricing buffers within your supply contracts. Thanks.

Yeah, so the challenge about making any sort of terribly meaningful comments about the impact of tariffs on our results is twofold. One is really trying to figure out what the tariffs are going to be, what countries, what the rates of the tariffs are going to be. As you know, they've changed quite a bit just in the four or five weeks of the new administration. The good news, I think, which you sort of alluded to in your question is that A great many of our supply contracts are multi-year contracts that essentially have pricing protections so that the risk of tariffs or the risk of increased costs really fall on the manufacturer while those contracts are in place. So I think our sense, and we certainly didn't really provide for any significant impact on our supply expense in 2025 from the tariffs, and I think that's generally our point of view. it's entirely possible that that changes depending on these dynamics. And as you suggested, retaliatory tariffs and that sort of thing. But we'd have to see how that plays out in sort of the real world before being able to quantify this in any more meaningful way.

Understood.

Appreciate the comments here. One moment for our next question. Our next question comes from Scott Fidel with Stevens. Your line is open.

Hi, thanks. Good morning. First question, just can you give us just the split when looking at the net supplemental payments for 2024, the $1.016 billion, just what the split is between acute and BH from that, and then similarly with the projection for 2025, you know, whether that split seems similar or if there's any directional change around that?

Yeah, I mean, honestly, I don't have it right in front of me, Scott. I think they're split relatively evenly between the two segments, but I can move back with you after to be more precise about that. And, no, I don't think the split changes much in 2025, again, as we've sort of talked about before. I think the 2025 assumption is that most of the programs kind of continue at their current level.

Okay, got it. And then I just want to follow up. I know AJ had asked a bit about the increase in the insurance revenue. You know, we were just looking at the CMS data this week. Looks like your MA plan actually had some healthy growth. So that seems to be a driver of that. Probably not where I would see that getting to $200 million, though. So, Steve, maybe if you could just walk us through, you know, clearly it does look like the MA plan piece is a driver of that that maybe just sort of walk us through from a product perspective, you know, what's building up to that 200 million?

So our subscriber population is split pretty evenly between MA patients and commercial patients. I think most of the growth next year is in the MA population, but we do have both MA patients and commercial patients, so Again, it's a relatively small plan, but as we continue to gain more experience and establish a track record in the various markets where the plan operates, we're able to attract more patients, et cetera. So the $200 million, I think, is reflective of the amount of new subscribers that we have.

Got it. If I could just one quick question to a last one. Just around accruals that you have on the balance sheet, legal accruals for behavioral litigation, just any updates on sort of where you ended the year on that and sort of, you know, how that may have sort of evolved in terms of any assumptions there. Thanks.

Yeah. So again, I mean, in the legal section of our 10 K, you know, we, you know, describe the status of the two large malpractice cases and malpractice verdicts that we had in 2024. Um, uh, you know, I suggest, you know, people can, can read through those. Um, we don't have specific reserves established for those cases. They're, they're going, we're both going through an appeal process and significant, obviously, as I said earlier, when our third party actuary goes through their, exercise, they are taking into account all of cases, decided cases, pending cases, appealed cases, et cetera, as well as cases that have not reached that level and they're putting a value on cases that have incurred but not yet sort of been filed, that sort of thing. So all that I think has been taken into account in the actuarial calculations.

okay thank you one moment for our next question our next question comes from Ryan Langston with TD Cowan your line is open hi thanks the SWV for performance and behavioral was the strongest I think in actually quite some time can you maybe just update us on the labor trends on BH like if that was just related to specific facilities geographies or job classes and I guess how How does, if at all, the fourth quarter like inform the 2025 guidance?

Yeah, I mean, I think we have been saying for a number of quarters now that the labor supply demand dynamic within behavioral has clearly improved from, you know, the really significant pressures that we experienced during the pandemic. And so, you know, I think you're seeing a combination of things that are really, of contributing to that strong performance i think number one um you know productivity has been improving um you know where we've got the the right number of people for the right number of patients to care for patients uh safely and and um and um providing you know top quality care um but you know we've also seen a moderation in the use of premium pay and outside Temporary labor, and we've seen a moderation in wage inflation, and all those things I think are contributing to the strong sort of productivity and efficiency performance that you've noted.

Got it. And then just piggybacking on the leverage in the share repo, just kind of where the shares are trading and kind of what's going on in the market, is there a potential that the repos for 2025 are maybe more front-loaded than maybe they have been in the sort of last couple of years. Thanks.

Yeah, I mean, obviously, you know, when you talk about what's going on in the markets, that changes day by day. So a little bit hard to make, you know, a judgment about exactly, you know, how the trajectory is going to look for the year. But it's certainly a consideration on our part. What I would say historically is, you know, our share repurchases tend to be – kind of more programmatic and rateable rather than really trying to time market changes, et cetera. I don't think we view ourselves as, you know, particularly good at market timing. What we do believe and what we try and take advantage of is, you know, the prospects of the business. We have a lot of confidence in the business and, you know, we're willing to invest in, you know, if you will, you know, buying back our own EBITDA, what we think are pretty attractive multiples and I think that's the case now and honestly, I think it's been the case and probably will be the case for some time. So I wouldn't commit to any particular sort of trajectory for this year. But, you know, as we have been for the past several years, I'm sure we will continue to be an active repurchaser.

Thank you. One moment for our next question. Our next question comes from J.B. Purse with Goldman Sachs. Your line is open.

Hey, good morning, guys. Jamie, could I just interrupt? But this is going to have to be our last question. We have another commitment after this.

Sure. Thanks for sneaking me in. I guess just on commercial payers, what are you seeing in terms of, you know, payer activity and denials, prior authorization to midnight rule implementation, et cetera, and just sustainability of rate growth, particularly in the behavioral business? It's been very strong.

Yeah, so I'll take the second part of your question first. I mean, we've talked about this for some time now, You know, we've had really strong behavioral pricing over the last several years. I think that's a function in large part of the scarcity of supply of beds and care in the behavioral space. And as a consequence, you know, we've been able to negotiate, you know, higher rates from many of our payers, payers who, you know, really, you know, are struggling to find a place for their subscribers to be treated, et cetera. I don't know that that dynamic has changed a great deal. There's not a ton more, you know, particularly inpatient capacity, I think, in the space, et cetera. So, again, I think the pricing environment for behavioral remains strong. You know, as far as sort of payer behavior, I don't know that we would, you know, sort of suggest that there's been a significant change, I think, you know, this is sort of a day-to-day issue with us. We find payer behavior broadly challenging, and, you know, it's kind of a daily struggle with us. We've devoted a significant amount of resources to making sure that, you know, our claim submissions are as efficient and as clean as possible, that our appeals processes are as efficient and as clean as possible. It's been a huge focus of ours, and unfortunately, I think we'll have to remain that because I don't see payers all of a sudden becoming much more lax in their utilization review and denial management, et cetera. So it would be great if that dynamic were to change in our industry, but it doesn't seem to be something that's likely to change in the near term.

All right, great. I'll leave it there in the interest of time. Thanks, Steve.

Thank you. So, operator, I think that's going to have to be the end of it for us. We'd like to thank everybody for their participation and look forward to talking with everybody after our first quarter results.

Thank you, ladies and gentlemen. So, that concludes today's presentation. You may now disconnect and have a wonderful day.