HCA Healthcare, Inc. (HCA) Earnings Call Transcript & Summary

Well, good afternoon, everyone. Thanks for being here. I'm Craig Hettenbach. I cover the health tech and provider space at Morgan Stanley. Very pleased to have with us HCA this afternoon, CEO, Sam Hazen; and CFO, Mike Marks. So welcome.

Thank you.

Thank you.

Before we get started, I just have to read the disclosures. You can find them at the Morgan Stanley website, www.morganstanley.com/researchdisclosures. So with that, and this plan to talk about these days, I thought we'd take a step back just to almost coming up on a year, time flies your first Investor Day and just to set the tone of this conversation of the importance of holding that event, strategic priorities and kind of how you're executing on that.

Well, obviously, we hadn't done an Investor Day for over 20 years, which maybe that's a record. I don't know we went private during that time period than when we went public and so we thought we ought at some point have an Investor Day. And for us, we had a couple of objectives there, Craig, and that was to make sure everybody understood what we determined to be sort of our pathway for going from strength to strength as an organization. And we also wanted to showcase a couple of things. One, the unique staying power, we felt of our company's role in different communities across the country that staying power manifested itself through different cycles, different major policy events, Affordable Care Act, to COVID, to different economic cycles and so forth. And we've tended to come out on the back side even stronger than we were going into those different cycles, and we had the same thing happen with the pandemic. And then the second objective we had was to showcase the management team. We have an incredible management team as an organization, and we had some new people in their roles, and we wanted to show that depth to our investors. As it relates to where we are with our strategic initiatives, Craig, we're moving into what I call the next pathway to really what we believe will be a very successful decade for our company. We have come out on the backside of COVID with more momentum we felt and we had going into it. We've improved, I'll say, the culture of our company throughout the COVID pandemic and just how we dealt with, people, how we dealt with community, how we deal with government, our shareholders and so forth. The second important element is our competitive positioning improved throughout the COVID period, and we find ourselves with more market share today that we had at the end of 2019. So that's encouraging. We were able to make some investments. We were able to do a few tuck-in acquisitions, add some programs and continue to execute what we call winning plays inside of HCA to help us with that. And then the third thing, and this is helping us think about how we're going to push through into the future here is our financial position actually improved. Our leverage ratio is better. Our cash flow continue to grow. And overall, we've been able to use that capital to invest back in the business at greater levels, number one. And then number two, if we finish the year as we expect with respect to repurchasing shares, we will evolve back $25 billion worth of the company's stock in the last 4 years. And so that formula of generating operational excellence and reasonable operational growth, coupled with the optionality that we have with our capital plan, we think, really presents a nice pathway forward. We have 3 major initiatives as we push into the future. One is continued network expansion. We see opportunities organically to meet our growth objectives by investing in our systems today. We're fortunate that we have a great portfolio of markets that we serve, and those markets are uniquely positioned. We think to benefit from some of the migration that's happening in the country, moving from the Pacific Northwest or California to Texas or Florida, the same from the Northeast. And so that's helping to structurally lift, we believe, demand in these markets. So our first priority is to invest in our local health care systems within these 43 markets that we serve and continue to build out outpatient capabilities, add inpatient capacity where appropriate and just integrate the network more effectively to meet the needs of our stakeholders, and we think that presents a really good opportunity for us to continue to grow, achieve some market share objectives and so forth. The second major strategic initiative for us is really geared towards tapping into the embedded value that we see inside the company that heretofore we haven't been able to get because we haven't had the tools in our toolkit today. And I know every CEO that sits on this stage is probably talking about, AI. I will tell you, AI in our business is a game changer for us simply because of the amount of processing that takes place in our organization with administrative functions because we're super regulated, as you know. Operationally, we can manage our business better using tools like this. But the holy grail for us is really pushing into the clinical setting and taking advantage of the large data sets that we have and bringing the learnings from those patterns that we know exist across our organization back to our physicians, support our nurses and really create a much better patient outcome. So we're very excited about what the second agenda can do for us, and that's to unlock this embedded value both on quality and on efficiency. The third is sort of I said it to you, it's a bit of [ rents ] and repeat. We have an incredible amount of optionality because of the cash flow that we produce. So we use that free cash flow to invest in growth opportunities, yes, but we have opportunities to use the excess to deliver value to our shareholders, and that's where our capital allocation program comes into play. And we think that formula of network expansion improvement in our operations through digital tools, combined with this ability to allocate capital productively, we think is a formula for shareholder value as we push through the rest of this decade.

Got it. That's great. And I want to build on some of this, it's always encouraging to see a company like you said that no matter what market you're coming out strong on the other side. And so we've seen a lot of change in health care loads for the pandemic, how health care is consumed and just given the scale and breadth of your organization, inpatient, outpatient, you have a lot of vantage points and visibility into that. How is HCA evolving to meet the needs of patients and how that's changing?

Well, I think it's, in many ways, changing less than people perceive. And that's simply because if you're in a car accident, you go to the emergency room. 20 years ago, if you were in a car accident, you went to the emergency room. So I think on the fringes, there are changes. And that's where telemedicine, that's where different kind of primary care models may have some implication, but largely at the core, there's not a lot of change. You still depend on your payer for which networks you can go to. You still depend on the doctor to give you some sense of where he or she is comfortable in doing a surgery or cardiac cath procedure, or whatever the case may be. And then you depend on your emergency rooms that are in your community when you need an emergency. So the patterns of purchasing health care are less changed than people believe. Having said that, we recognize that we have to be responsive to these large growing communities and some modestly changing patterns of how people purchase. So we're investing heavily in our outpatient network first. And with our outpatient network, our approach is to take as many outpatient facilities as we possibly can and make it closer to the patient. That's convenient for the patient, different price points for the patient, and so forth, very efficient for the patient. But for us, as a system, what it does is it opens up the opportunity for us to interact with the patient upstream. And if they need acute care downstream, we can integrate them hopefully about having the necessary programs or services or physicians in our network and receive them if they need acute care offerings. So we're a hospital-centric health system. We think the hospital at the core allows us to extend the reach and create the local scale that's necessary for us to meet the patient's needs. So that's one aspect. It's more outpatient development. Today, we have roughly 13 or so outpatient facilities for every hospital. It's like a mini ecosystem. We connect those to all the hospitals in the market. So a market like DFW, as an example, we have 20 hospitals. We have almost 500 outpatient facilities in the Dallas-Fort Worth area, and we're continuing to extend the reach of our outpatient network in the Dallas-Fort Worth area and that allows us to meet the growing needs of the community, but also support the downstream opportunities we have within our hospitals. So that would be the first thing. The second thing is we're supporting patients in their journey. So we have a lot of navigational support. We do it with nurses. We do it with infrastructure like our patient logistics centers. We're doing it with mobile apps, all of these things to help our patients get a schedule more timely, navigate the system if they need resources. And so those are some of the things that we're doing. We're very advanced in telemedicine as a company. We probably have 600 sites of telemedicine, but they're really geared towards supporting the health system more than their retail-oriented on the primary care side. And we do telemedicine on the primary care side. So we have all of these components out there that are really connected to the system locally from one market to the other. So those are some of the things I would point to.

Got it. And as strong as the business is, there are still kind of debate, particularly around supplemental payments, advanced subsidies and HICS. I'd love to get your thoughts there in terms of the importance of the current business and how you navigate around this.

Yes. I always tied the Medicaid supplement payment programs back to Medicaid. They're really kind of core to our Medicaid programs. I think we've all talked about this before, but Medicaid supplemental payment programs are really essential to helping providers and health systems take care of the Medicaid population and provide access to that community for care. And we kind of connected to that. I mean right now, it's fairly steady. We've had 18 of our 20 states that have supplemental payment programs. So we've largely, over the last several years, seen those kind of grow, but now most of our states and all of our big states have programs. They're pretty variable. And so you see states change on an annual basis. Some states have multiple programs. So we tend to talk about supplemental payment programs more on an annualized basis. Because of the variability of the timing and the amount of revenue and expenses associated with them. But at the end of the day, I always remind people that even with supplemental payment program revenues and the related expenses, the reimbursement still doesn't cover the cost of care. So I think the supplemental payment programs are long-standing. They feel durable to us. They've survived through Republican administrations and Democratic administrations and we continually work with our states and our other provider system partners as we go in the future. And I think we're seeing it being fairly stable as we go forward with always some chances for enhancements as we continue to work through that. On the health care exchange subsidies, the enhanced subsidies. I think everyone knows that right now that they would be scheduled to sunset at the end of 2025. There's kind of a long time between now and the end of 2025. We got to get through the election. We've got to get a sense for the balance of power, both at the president level and at the House and the Senate level. But we believe that there's a lot of opportunity here politically, both in the beltway and in our states. I mean, there's a lot of people that have health care exchange coverage in our states. Think about Texas and [ Fort-Worth ] as two big Republican dominated the states where there's a lot of covered lives. And so we'll be working both politically and through our resiliency programs to first try to get the enhanced subsidies extended into additional periods. And then to the extent that we don't get them fully extended, and we're going to be working on our resiliency programs to try to create as much offsets to compensate for that over time. The last thing I would say is if you look at HCA, even through multiple years of challenge, we've been able to maintain a pretty steady margin profile of about 19% to 20%. Through the COVID pandemic, through the staffing challenges and the wage pressures that we saw over the last several years. And then lately, even through the professional fee inflation, even with those challenges, we've been able to work as a system and leverage our management teams to identify opportunities to navigate those. And we're going to do our best to navigate what may happen in '26, and we'll deal with those challenges as they come.

Great. I would like to touch on just the competitive landscape in understanding it's typically kind of regional in your markets. But just how you're faring? I think one of the points at the Analyst Day, you've increased market share. So directionally, you're moving the right way. But can you touch on just competitors in important markets to you and how HCA is faring.

So we defined our provider model, if you want to call it that archetype for an HCA system back in 2011, and we continue to refine it. We continue to plan around that, resource around that and really execute at a high level, Craig. And that's been part of our growth paradigm. Obviously, we invest heavily in capital and people to make that happen, and we'll continue to do that. We grew our market share from 23% in 2011 to 27% in 2019. Today, we're about 28%. So we have 43 U.S. markets, one international market that we compete in the U.K. Central London primarily. Typically, we're #1 or #2 in those markets. There's a few markets that we're #3, but we believe we can execute a reasonable strategy and get a decent capability, service and return on capital. So mostly, we compete against local systems. In other words, in Miami, everybody in the Miami market for the most part is only in Miami. In Tampa St. Pete, it's mostly people that are only in Tampa St. Pete, but they're different in Miami. I go to Texas, the same thing. We have very few common competitors across our markets. And that's advantage and disadvantage in some ways. But for the most part, we find advantage because we have this diversified geography in our company where no one division creates any more than 10% of the earnings of the company. So we're diversified in that sense. And then we're diversified within the service lines that we offer where no one service provides any more than 15% of the revenue. We have had patterns. I think 2/3 of our markets are actually at a high watermark on market share and have grown compared to the pandemic. We've had a couple that haven't for whatever reason and some of it could be a competitor made a move, and we're responding to it and haven't fully recovered from it. But for the most part, our model has produced really consistent. And I think effective market share gains for us. And we believe we can achieve market share gains over the next 5 to 7 years by investing even more and doing some of the things I mentioned around our network expansion. So I think from a competitive standpoint, as I mentioned, we believe we've come out of the pandemic with competitive position with business momentum. We don't have good metrics right now on exactly how much share we've gained in '24. But the most current data we saw in '23, which was mostly through the third quarter, we've seen a pattern of modest growth that gives us confidence that we're continuing to take advantage of some of the demand. I think it's important on the demand side to understand what's happening in our markets. First, we've had a lot of population growth, as we mentioned, and that's lifted demand, we think, structurally in our markets. The second thing is more people covered, we believe, does drive up demand. We still are seeing aging baby boomers hit the system and start to lift the demand curve a little bit. And then finally, we've been able to gain market share. And so we think those elements are in play. They're obviously in play this year where our volumes are exceeding our guidance significantly. And we even raised our guidance at the beginning of the year on what we thought volumes were going to do in 2024 above our long-run objectives. And so we're pretty encouraged about where we are. We're going to need the last part of this year to really judge, I'll call it the durability of all that and see what's structural and what's may be temporal. It's hard to discern that on the fly, but we're trying to study the business as best we can to make some judgments around that, but we're pretty encouraged by where we are from a competitive standpoint.

Sure. Maybe just sticking to the demand. And you started the year kind of 3% to 4% equivalent admissions growth. I think you've been above 6% in the first half of the year, so very strong. And I don't think most investors expect that to continue. I think the debate is, do we kind of decelerate modestly? Or at some point, could you get an air pocket -- you mentioned some of the maybe structural factors of population growth, baby boomers, how are you kind of sizing all this up in terms of your view of just durability, where we are and what things look like.

We do think over the long run, demand is durable. And we said that at our Investor Day and nothing's changed that, if anything, it's reinforced our belief. What we don't know yet is it above the 2% to 3% that we guided to, if you will, on our long-range demand beliefs. We're just not ready to call that yet. I'm not sure we'll be able to call that fully by the end of this year. We're probably going to need to go through '25 see how the Affordable Care Act extension of the subsidies plays out because, again, coverage has an impact. But when you just look at the metrics and you look at the forecast, we think that 2% to 3% is a fairly likely scenario for demand growth in our markets. And if we can pick up share, maybe it's a little bit higher than that. And then if we see some structural lift that we weren't anticipating, we'll definitely make an adjustment to that guidance when it's appropriate.

Got it. And anything else you can share when I think -- when we think about kind of the outsized growth this year, whether it's from an acuity perspective or just things you're seeing in the marketplace that are helping. .

Well, I mean, our payer mix has been very good. We've seen really growth across the different payer classes. Obviously, the exchange and the HICS payer class has grown the most, but regular Medicare has grown, Medicare Advantage has grown significantly. Medicaid has backed up a little bit. Regular managed care has grown at a very good pace. So we've seen broad growth across all payer categories, number one. Number two, all of our geographies, all divisions, 15 domestic divisions, the U.K. also has had demand growth and volume growth this year. Across our service lines, we have about 18 to 20 different service lines that we study. With the exception of behavioral health and outpatient surgery for us, which we've highlighted on our calls have all grown. So we've had broad-based growth there as well. Within that, the volume has been more acute. So our acuity levels, within our inpatient business has lifted. And even in some of our outpatient categories, we've seen more acuity in our service offerings. And we do think that's structural because our acuity today is up over where it was in 2019, and that's in the face, Craig, of losing orthopedics as inpatients, they've migrated to outpatients and their acuity level, as measured by our case mix index was actually greater than the average. So that suggests to us that the patient cohorts that we treat today definitely more acute. We think that is sort of a stable trend. And I'll add to it with this point. Because rural demand is growing in the urban markets. And by that, I mean, rural health care is undersupplied and the folks in rural communities tend to migrate to the urban market for health care. That's always been the case, but it's accelerating. And we're seeing more demand coming from the rural markets into the urban markets. That demand carries higher acuity. So we have a lot of infrastructure, a lot of outreach efforts into the rural communities so that we can be their network solution, if you will, for patient care when it's needed. So we have relationships with rural hospitals. We have relationships with rural E&S. We have logistics centers that navigate the patients into our system. We have transport asset, fixed wing, helicopter, ground capabilities to move patients as needed. So all of that is connected to a strategic agenda of ours, which is to add complexity to our service offerings so that we can take care of more acute patients as needed.

Got it. I wanted to talk about just some of the operational transformation and initiatives at the company. I heard the excitement before about AI and share that in terms of the use case. But the $600 million to $800 million of potential savings over time, can you just give a little bit more context there in terms of some of the initiatives that you have and just the confidence to execute on that over time?

We're feeling really good about our resiliency program. It's maturing. It's strengthening. It has good momentum. We really kind of talk about our resiliency program, mostly in 3 buckets. The first kind of bucket or category of work is expanding our shared services and providing even stronger corporate support now to support our local health systems. We've had historic strength in our revenue cycle with Parallon. We have historic strength in the supply chain with HealthTrust and we're starting to see more opportunities to leverage shared services to better support our structures. I'll give a couple of examples. The laboratory service line, where we've historically had laboratories in each of our hospitals. And we started moving in our big markets into more centralized automated laboratories that can better support our facilities with technology at a much lower unit cost. We're also finding ways to better support some of the administrative and operation categories in our facilities like our environmental services, our food and nutrition services, our plant operations and we're finding that a support model can help us with people, with processes and to bring better effectiveness and better efficiency in some of the core operational components of our business in the hospitals. The second way that we are driving our resiliency program is really through digital and AI and Sam already mentioned this, but if you look at the ability to use AI machine learning, automation, process automation capabilities and these big administrative platforms, and we touch 42 million patients a year. If you think about the medical supplies that have to come from all over the world, logistically into big warehouses and to our operating rooms in our Cath labs at the right place at the right time. This is a world of data that we can use to find better insights, take better action and drive better efficiency. So we believe strongly that our digital and AI component is going to help us with our resiliency program, and we're finding lots of opportunities to do that. And then the third thing is really our benchmarking and our analytics and reporting capabilities are continuing to improve. I know that sounds really basic, but when you think about 188 hospitals and the kind of patient volumes that we see, there's a lot of variability. And in that variability is opportunity. So we can find the best practices in those hospitals that perform the best. Learn what they are doing to drive that performance and then transfer those as best practices across the rest of the facilities. So there's a lot of examples of that. I mean one that I would give would be our case management, our length of stay agenda, where we've been hard at work over the last 2 or 3 years, really focused on people, process and technology in that component of our work. And it's already paying a dividend. So our length of stay is down almost 2% June year-to-date compared to prior year, and it was down 3% in 2023 versus 2022. And the components of our resiliency program are focused on that are helping to drive that result. So I think the resiliency program, if you look in the short term, we're using those savings now to fund our investments in our technology and innovation agendas. But then as we kind of continue in the future, it allows us to deal with challenges, things like in 2026 if the enhanced subsidies go away. And then as we get to the back half of the decade, we believe that our resilency program should help us push forward on margins as well. And so good momentum, a lot of work streams across all categories of the company, and we feel good about where we are right now.

Got it. Can we touch on just maybe just partnerships? I know you've been working with Google Cloud so the last three plus years, you have something with Palantir for scheduling, MEDITECH on the EHR. So how do you kind of leverage some of the internal initiatives as well as working with these partners? .

So that was one of the things we learned during COVID that we don't have to try to figure everything out on our own. And during COVID, we committed to using partnerships wherever we needed to, to help us get through the pandemic. And I think that opened our eyes a little bit further to the need to bring some outside resources from outside, perspectives into HCA. A lot of us have been with HCA for our entire careers, and we don't know everything about everything. And so having partnerships is really important. In the technology space, that's obviously significant for us. I mean, Google is helping us with managing Big Data and how to really turn it around quickly. So that's been a very productive partnership for us so far. Palantir has helped us use AI in evolving our first sort of digital product that we're pushing into our operations, and we're seeing early signs of success there. And then we have other partnerships that are necessary for us on our digital agenda. The partnerships are way beyond just technology. I mean we structure our sort of model around partnerships with physicians, whether it's partnership in an ambulatory surgery center or just partnering with them in the operations of our hospitals, so that we're responding to their needs in an appropriate time. So that's sort of embedded in the culture of who we are. We have to build relationships -- we have to build partnerships of trust. And if we can do that, we can advance our business, we think, with some of these tech partnerships into others. We've got a great partnership with McKesson with our Cancer Research Institute, and we're seeing early signs of success with that. We have other partnerships where we have relationships with different entities in different segments of our business. And so I think from that standpoint, it helps us advance our networks. And again, like I said a minute ago, we own most of the assets in our networks, we have a lot of affiliates. We have some partnership assets that are connected to it. And this is just another extension of that with these 3 tech companies that you mentioned.

Got it. Can we touch just on labor and contract labor is going the right way. You've mentioned kind of professional fees, you're kind of working through. And despite that, kind of the margins have been coming up. How are you kind of managing what's still been kind of a tight labor force and also anything from a nursing school, like how you leverage things like that? .

Yes. So workforce development is critical to HCA. To your point, I mean, if you go back to the height of the pandemic, we were using almost 10% of our SWB and contract labor. And -- and now we're down -- we're at 4.8% in second quarter. We've kind of guided in the back half of the year to mid 4s and that's the financial output of a lot of hard work. And that hard work looks like our management teams and a lot of corporate support reducing turnover, improving recruitment and hiring and then really focusing on kind of the supply of nurses and physicians into the marketplace. And if you think about Galen as an example, they're up to by the end of 2027, we have 30 campuses and 30,000 students in our Galen School of Nursing. And it's a powerful engine to help us kind of integrate the nursing school into our provider health systems and help with the supply of nurses and it's integrated. So the nurses you graduate have an opportunity to be really connected to HCA. And so it's a big part of workforce development. On the physician side, we have over 5,000 residencies, residency slots now where physicians when they graduate medical school come for training. And this helps us create a pipeline of physicians as we need to grow our medical staffs in our community. It creates a strategic asset. And so when we're dealing with challenges like professional fees and a lot of that's hospital-based physicians, the residency programs help us ensure that we can recruit and retain the right specialists in the right positions to support our operations. So workforce development has been a key success for HCA and I think it's got a lot of potential for continued improvement over the next several years.

Got it. So I think we can bring together a lot of these themes as we kind of wrap up here and focus on capital allocation. You mentioned $25 billion of stock the last 4 years. So how are you approaching kind of buybacks, inorganic growth opportunities, you're also investing in the business in terms of drive growth? Can you just kind of give us a current state on that.

So this year, we will invest capital of about $5.25 billion back into our networks to, again, add to our ambulatory platform, increased inpatient capacity, add clinical technology, IT investments and so forth. So that will probably grow some over the next 3 to 5 years, simply because we're at an all-time high on occupancy. We're more efficient through the case management agenda that Mike alluded to than in past years. But yet, we've grown more. So we're at an all-time high on occupancy levels for inpatient beds. We have about $6.2 billion of capital right now that's in the pipeline that's been approved. It is in some phase of development or construction and will come online the balance of this year, '25 and most of it by '26. So that's going to add to our bed capacity. It's going to add to our outpatient facilities and so forth, we pay a modest dividend, and we've had growth in that dividend over the past number of years. And as we go through our year-end planning, we'll land on exactly what we're going to do with that for the upcoming year. But capital -- the free cash flow that we generate gives us a lot of optionality. And again, we've used that to buy back shares, which we felt was really a productive opportunity for our shareholders, given the valuations of the company at that particular point in time. And even today, we still feel like there's upside value, intrinsic value, if you will, a company that's not necessarily reflected and so we still see opportunities for us to do that. As we move forward, I don't know that we'll deviate significantly from sort of the formula that we've used, but we need to sort of plow through our planning process. But as an investor, the fact that we have this kind of free cash flow and optionality with it, I think, really gives us a lot to work with.

Got it. And then just lastly, on M&A, it's been focused more on the outpatient side. Does that continue or how do you...

Well, I mean, obviously, we would love to be in new markets. The problem is the assets don't come up for sale. It's a different industry that we're in. Most of the industry is tax exempted. They're not motivated by share price in the same way as other businesses are, so asset optimization isn't happening at a pace like other industries. So on the outpatient side, there are a lot of those type of businesses out there. And over the past number of years, we've added outpatient businesses in market to extend the reach of our health care system. In Tampa St. Pete, we bought an outpatient business last year, which added to our urgent care platform. In Houston, we bought an outpatient business that added to our emergency room capability. In DFW, we bought a small little hospital, rural hospital system that actually had a couple of assets in market. So that extended our DFW capabilities. So we do some ambulatory surgery center acquisitions here and there. Physician clinics. Those are really complementary. They're not large. We don't talk about them much externally, but it's part and parcel to really extending the reach of our networks in market. So we have put a little bit of capital towards that. I don't think we had a significant amount last year nor will we have a significant amount this year, we believe. We do have one acquisition in Manchester, New Hampshire, which will complement our New Hampshire assets. It's a tax-exempt system that's selling to us, and it will round out our New Hampshire network in a way that we think is productive over time.

Great. I think we'll wrap there. So Sam and Mike, thanks so much for the time and being with us this afternoon.

Thank you.