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

All right. My name is Justin Lake . I cover health care services here at Wolfe Research. Appreciate everyone being here with us today, especially the executives from HCA Healthcare. So excited to have Mike Marks, the company's CFO, with us, Frank Morgan, the Prince of IR, is also here in the audience. Appreciate you bringing Mike up. Frank, thank you. So let's get started with a little bit of a grounding on kind of -- you come out of a solid third quarter, right? You gave us some range of guidance that I think is kind of in line or at the higher end of your long-term growth targets. Talk to us about what the assumptions were that were kind of built into the fourth quarter relative to your typical 2% to 3% volume, 2% to 3% growth or pricing, I should say.

Yes. So as we think about third quarter, third quarter was strong, as you noted, both in terms of volumes, same facility admissions up 4.5%, good rate, 13.5% growth in adjusted EBITDA. So really strong third quarter. That included the $50 million hurricane impact from Hurricane Helene that we noted for third quarter. And then as part of our third quarter call, we updated our guidance for the full year. And really, what we said was we're reaffirming the guidance, but we would steer people to the lower half of the range. And -- that was largely due to the hurricane impact that we had estimated in fourth quarter to be somewhere in the $200 million to $300 million range. So if you just think about kind of the landing point for the year, it's really a continuation of what we've seen for the first 3 quarters in terms of our operating performance, but we had to take into account the impact that we estimated from the hurricane. So that's kind of how we got to the conclusion of steering people to the lower half of the range.

Got it. And as you think about that hurricane impact, first of all, that $200 million to $300 million how is that kind of shaping up now that you're halfway through the quarter? Does that seem -- do you think that number ends up higher end or the lower end, maybe above or be below?

Well, I think we're -- we would stay with what we've guided at this point. The guidance kind of contemplates the facility in Florida, Largo Medical Center reopening by the end of the year. So we have a lot of work in flight to get that facility reopened. And so that's a pot. It's about half of the $200 million to $300 million is in Florida, the other half is in North Carolina. And so we're watching carefully and working in North Carolina to support that community. And so we'll have an update for you in fourth quarter. But right now, I would say that $200 million to $300 million range that we estimated on our third quarter call is where we would still guide.

Got it. So in total, we're thinking of a hurricane impact of $250 million to $350 million, right, including the third quarter, $50 million. So you go to the high end of your typical 4% to 6%, right? So we're going to be closer to 6%. You talk about the above-average volume growth expected, right, relative to the typical 2% to 3% that's kind of building that kind of driving that. The -- but we're also -- gotten tons of questions on, okay, they were carrying $300 million at the midpoint of hurricane costs, how much of that goes away next year. My impression is you don't think a lot of that goes away. You think the mix of it changes, right? So for instance, the Largo costs start to dissipate but now you're carrying a full year impact of North Carolina, right? Because it's going to take some time for that unfortunate situation to rebound. So maybe walk people through kind of the moving parts there and how you think about next year's hurricane impact versus this year's hurricane impact.

No, I think you summarized it well. We do believe that our Largo facility in Florida will recover. Will it ramp all the way back to where it was pre-storm. It usually takes a little bit of time market will recover. So you'll have a year-over-year increase from the Largo operation coming back online. But I do think that the impact of the hurricanes in Western North Carolina will linger into 2025. Given the impact to the population and the community infrastructure that we're having to support at this facility. And so largely, our best estimates and best thinking right now would be that the recovery in Florida, at Largo will largely offset the year-over-year decline in earnings that we think will happen in North Carolina. So that will be a bit of a push between those 2. So when you think about the early look observation that we gave for '25, we said that we thought that our adjusted EBITDA in a bit of a range, but would be somewhere near or slightly above our long-term guide and that's inclusive of that -- of the impacts between Largo and the Western North Carolina related to hurricanes.

I think the impression I've gotten and I think as people listen to you speak, like the thought process is that's a pretty stable number year-over-year. Eventually, it comes back as North Carolina rebounds, but that's going to take time given the infrastructure hit there. But that $250 million to $350 million is not going to change much in 2026 or 2025, I should say. And so your core kind of growth is that high end of the range, is the way to think about it?

I think that's right. Now I do think North Carolina recovers over time as we get further out into the future. We'll see where that goes. And the only thing I might note, Justin, is the numbers we have given you do not include insurance recoveries. So just keep that in mind. So all of that is exclusive of potential insurance recoveries that we do expect we will get I don't think we'll get them in 2025. So I think insurance recoveries are going to take a little bit longer, just kind of given the complexity of these claims.

Got it. And then the other interesting swing factor is these Medicaid state directed payments right? Certainly, coming into 2024, I think you took a prudently conservative approach given all the moving parts there. It's ended up being better as you head into 2025, should we think about that as well as kind of will probably start out given all the moving parts somewhat conservative? You know I get questions on Tennessee, for instance, right? He's putting a new program in place. It seems like it's just a matter of time. Are there enough moving parts where you feel like that's not going to be a big swing factor? Or what do you -- how would you think -- how would you tell us to think about that within the guidance?

So as we think -- and I think this year is a great example. And these programs are complex. They're variable. They're tied to Medicaid, right? And so if you think about kind of Medicaid is our -- is really our worst payer, except for people without insurance.

Sure.

And even with the growth of the supplemental payment programs over the last several years, the reimbursement when you take traditional kind of base core Medicaid reimbursement plus the Medicaid supplemental payment programs, are still short of the cost of care, right? So that's the context I always like to give around supplemental payments. As we came into 2024, you'll recall, we thought that it could even be a tailwind of a headwind of $100 million to $200 million. And then as we kind of got midway through the year, there was enough kind of movement that is suggested it would be a tailwind of $100 million to $200 million. And then in third quarter, we even said that we thought that it could be at the high end of that range, right? So there's obviously moving parts. As we think about 2025, it's a little early to give precise guidance on submental payments. We'll do that in January on our fourth quarter call, like we always do. But I do think it's important to note that we took into account everything that we know and what we can forecast around supplemental payments in that early look observation of being near or slightly above our long-term guide. So I would think of it as being inclusive of what we know. And then, again, we'll give fulsome updates in January when we have more information.

Perfect. So I think that's a good place to kind of shift over to what's going on in Washington, right? There's a lot of questions around DPP and exchanges. So let's start with DPP, right, these direct in payment programs. There's not a mechanism in place for those to change, right? So the expectation I would assume, is steady as she goes. But there is some concern that maybe not that it's a legislative priority, but you're going to have Elon Musk and some of his buddies looking to cut costs and could this be a place where they take a look. Anything you're hearing there earlier? Or how do you feel like the tenor of the conversation is kind of going into a shift in D.C. right now?

As we think about Medicaid supplemental payment programs, the one thing I would say is they're long-standing, right? But if you think about these programs have been in existence for decades, have programs going back 20 years. We've seen good support for Medicaid supplemental payment programs in our Republican states and our Democratic states over the last many years in the past Trump administration, the Biden administration and like. I think if you think about the legislative support and the political support for these programs over time, we view them as being way more durable. The safety net hospitals across America really rely on these programs as well. So if you think about impacts to the health care system at large, it would be seriously meaningful, right? And so as I think about the new Trump administration and what their priorities be, I mean, just like you, they were fairly silent on health policy during the election. We're watching it carefully as they make their nominations and start getting ready for the new session. But we view the risk related to supplemental payment programs as being pretty low, and we view them as being durable. But I mean that doesn't mean there's no risk. It just means that I would put them as a far distant second on risk versus other components that I know we'll talk about. So.

Yes. Let's shift to the clear first, right? So the exchanges. Problem there is that if the administration does nothing, they sunset at the end of next year, they become a more material part of kind of the health care ecosystem, right? There you guys have done a very helpful -- been very helpful on at least identifying the volumes that, I think, 7% versus 4% pre-COVID and up to 8%, 9% of revenue, right? So from there, the next question obviously becomes, what do you think the contribution is from an EBITDA perspective, right? And it seems to me like that's where the company has kind of drawn the line and said, look, you can't just talk about that, which I agree with, right? A lot of people have asked me to publish like, hey, what do you think of this number? I can publish a gross number and just say, okay, it's 50% margin, and that's a lot of revenue and a lot of lost EBITDA but there's a lot more nuance to it, right? Where do people go, right? We don't know, right? Are they going to buy down in tiers? Are they going to go to commercial? Are they going to go to the uninsured? The one thing we know is that they're not going to go to Medicaid, right? Any other kind of key moving parts that you think people should think about or to be great, the -- for me at least, if you guys did put a margin around that and just said, like, here's what we think the EBITDA contribution is. Lets say, you're willing to do that today and maybe Frank is going to yell at you, but I'd love to hear it if you got it.

Let me start at the beginning of your question, and then we'll get through all the points. But I always start by saying let's first kind of focus on what we know and what we don't know. And what we know today that we didn't know on third quarter call is the output of the election. So we know that the Republicans have the White House and the House and the Senate. Although I would note that the House and Senate margins are going to be tight. And I think that's a piece of the story for sure. You've already noted that 7% of our volume are from health care exchanges, a little over 8% of our revenues. And we also know that these programs are really important for coverage in our communities. And there's a growing understanding that if these sunset and they don't get extended or extended in some modified way that there's a fair number of voters in these communities, including in these states that -- where a lot of these folks voted for Republicans that they're going to have tax increases, right, because they're going to lose some aspects of the premium tax credits. And so we are working hard with a coalition of other organizations to advocate for the extension of the premium tax credits. And I think there's a decent probability given the implications that a deal will happen. I think everyone is aware, the way that these were set up to sunset at the end of '25. The other thing that sunsets at the end of '25 is the individual tax cuts. And so I believe that they're -- we're hopeful and we're going to work to the end of having a deal where these 2 can be dealt with in a bipartisan way in the Congress and with the Trump administration. So that's our first goal. And so there's a lot of unknowns in what happens with that, that makes it difficult to navigate. To the extent that the premium tax credits either get modified or sunset, some folks, we believe, will stay on the exchanges. They've been widely adopted. They're well supported. People like the exchanges. You can see people dropping down the medal count from gold to silver, silver to bronze and stay on the exchanges. You can see some people go back to employee-sponsored insurance coverage. And then you would have some folks that would go to uninsured. And we've talked about this before, but the one thing I would note is for the folks that go back to uninsured, they tend to engage the health care market through the emergency room. And so you tend to have less elected business, which would reduce variable cost to a bit. And then the other component to just keep in mind is that if uninsured does grow, that you do get some pickup on your Medicare dish payment. So there's a bit of offset there. So as you can tell, there's a 1,000 variables here that we have to kind of get through the next 8 to 12 months before we're going to be in a position to answer the specific questions around the impact. To your question about health care exchanges, what we typically say, and here's how I'll answer it, is health care exchanges are second best payer. There -- they kind of fit between Medicare and commercial, and they're a little closer to commercial. So I think that will help you with your modeling.

All right. I appreciate it. Let's switch gears a little bit and talk about some of the IT investments you're making. So I just was flipping through your 10-Q, notice that your corporate costs were up pretty significantly, right, from, I think, $600 million to $1 billion year-to-date. So up $400 million year-over-year. One thing -- one of the reasons I asked is simply that's a lot of cost you've absorbed within a pretty good growth rate this year, right? So maybe talk a little bit about what's driving those corporate costs up and specifically some of the investments you're making on the IT side, how big are they? And what do you think of it going to be the benefits to the enterprise as you look ahead?

Yes. And there's a host of drivers there, not just 1 or 2. The 2 that I would call out that are a bit meaningful. One would be our investments in our tech and innovation strategy, and we'll talk a little bit further about that. The other one would be share-based compensation. But then there's a host of others that are some puts and takes in there. But -- as I think about our investments in tech and innovation, as we talked about at our Investor Day last year in October, and as we've talked about pretty extensively on our calls, we have a series of investments in flight that I'm really excited about, and I think we'll have a lot of value for the company. The first one is the rollout of a replacement to our electronic medical records. And so we're in the beginning stages a multiyear program to replace our legacy MEDITECH Magic system with MEDITECH Expanse and there's a lot of work involved with that and a significant focus of getting through that transition well. We're investing in our digital transformation agenda, our artificial intelligence, machine learning and automation platform and seeing some good early wins around that and see a lot of potential for the company. And when we think about our digital transformation strategy in 3 ways, we're using it to improve our clinical processes. We're using it to improve our operating processes and we're using it to improve our administrative processes. And so administratively, these are things like revenue cycle and supply chain and human resources. If you think about the size and scale of the company and the amount of data involved, the opportunity to use machine learning to find the variability in performance and then address that to drive better efficiencies and better effectiveness or immense of a company of our size and scale. The same thing applies on the operational side of our business. We talked about this a little bit at Investor Day, but I would mention, for example, that our investment in Timpani, which is our machine learning staffing and scheduling tool is now live at about 1/3 of our hospitals uses big data, predict demand and to help schedule our care teams. And you just think about 300,000 colleagues, 100,000 nurses and almost 50,000 doctors, being able to really use big data to be more efficient and effective at managing our operations is a lot of opportunity. And then we have the Holy GRAIL, which is our clinical processes. At the end of the day, HCA, our mission is the care and improvement of human life. And what we do is we take care of patients, mostly in hospitals and other health care facilities. And so the amount of variability that exists in our opportunity to find the patterns in those data and then use machine learning to take insights from that variability and bring them to our caregivers, our nurses, our doctors and allow them to make better decisions is immense. And it really is connected to our mission of taking great care of patients. So we're excited about our digital strategies, and that's part of that tech and innovation investments that we're making. We're also making investments in our cyber road map. And so the combination of those are part of that growth. I would say, and again, we've mentioned this before, in the short term here, we're using our resiliency strategy to really pay for those tech and innovation strategies, which is how we're getting to such a good growth rate in our income statement as we continue to invest. And then longer term, as we kind of make those investments and get through the investment curve, we believe that will really support the company and help us to improve our performance, our efficiencies and our effectiveness as we get into the last few years of the decade here.

Got it. Let's talk about physician staffing, right? From the perspective that, one, I think you've talked about the pressure you had starting in the back half of 2023, that is kind of annualized, you feel like you've got your hands around it. You've worked to offset it through some of the cost cutting you've done. The -- do you think that ever gets to a point where it's neutral to the company instead of being a drag from a pricing perspective. So I assume you're going back to the payers as part of your negotiations and saying, look, you're not paying enough for these physicians, right? We are now negotiating on their valve. How does that work? Do you think that's a big -- something that over the next pricing cycle is going to be able to get to neutral and how big would that be if it did?

So I think you have to think about this in context mostly of hospital-based physicians. And so these are anesthesiologists, radiologists, emergency room physician, hospital list and the like. And I mean you guys are aware of this. But these physicians are really important to run hospitals. And so it's key. I really kind of break the answer to our question in 2 components. And the first component would be where we have decided to employ and build our own employee platform for hospital-based physicians. And the best example of that would be Valesco, where we went from being a non-consolidating joint venture to owning it 100% and bringing over 5,000 doctors into HCA, into our management systems and control systems. And we've done that as we've gone through this year. And I would tell you that as we started the year, our performance in Valesco is right where we thought it would be. So we're kind of on our expectations. You may recall that as we started the year, we said we thought that would be about $150 million over 2024, and we're going to be there, if not a little better. And so I think over time, we may find ourselves doing more employment and less contracting for hospital-based physicians. We can talk about that as well. But when we're talking about going to payers for getting reimbursement, it's really on our employee book of hospital-based physicians for context. And yes, I mean, we -- when we work with our payers, this is now a big part of our negotiations. If you think about what happened to the hospital-based physician business model, it was under a lot of pressure in '22 and '23. You have the No Surprises Act. You had the payers really pushing down on reimbursement levels to hospital-based physician groups. And so they got upside down. And so the -- at the same time, there's physician shortages with those physicians. So their cost ended up being much larger than the revenue. And when that happens, they come to the hospital partner and say, you need to make up the difference. And so that's what drove kind of that business model. So yes, when we're talking to our payers, we're negotiating for a fair reimbursement for those. I don't know that it gets us to neutral. Kind of given -- if you just kind of think about Valesco as being an example, I don't know that it gets to neutral, but we certainly can make an impact over time and believe we have. If you think about our contracted business with the big hospital-based physician groups and anesthesia and radiology and the rest, that was a big part of the pressure in 2023 that drove professional fees up. As we've gone through this year, we've been working really hard with our operating and physician teams to bring structure around that and improve our performance. And I think you've seen that, right? So we've stabilized from -- if you go to first quarter of this year, we were 20% over first quarter of last year. Second quarter, we were 13% over prior year for professional fees. And in third quarter, we were 10% over prior year. So we -- you've seen kind of that sequential rate of growth go down. The only other thing I might mention is third quarter was sequentially flat to second quarter. So I do think that the results of our work with -- we brought some stability to our professional fee costs on our contracts. It's still an area under challenge and it's still an area as you go into '25 and beyond that we're going to have to continue to work hard on. But I feel way better today than this time last year as a result of the work we've done.

In 2025, do you think you can get that kind of growing at revenue growth? Or do you still think it's something that's maybe 2x?

Well, it's probably a little early to give exact guidance like that. But I definitely think that we have moderated this rate of growth. I mean I'm not expecting this kind of like we saw in '23 and a little bit in the first half of this year, this kind of significant growth over run rate. So I would put it more in that zone. We'll give you more precise information as we get into January.

And as we think out into 2025, right? So we had a salaries and wages as a pressure point, especially temp labor. I think that was kind of understandable given what was happening with COVID. The physician side came out of a little bit left field is a little bit of a surprise as it kind of evolved. Is there any kind of watch out areas that you would point us to as you go into 2025 that you say on the cost side, like here's the 1 or 2 things we're watching that could be a pressure point?

We're watching everything, as you can imagine. But I mean I think if you just think about the margin profile of the company, and we mentioned this on the call for third quarter too. I mean I do think largely, we're looking for a fairly stable operating environment from '25 to '24, I think labor would fit that, that kind of construct a fairly stable wage inflation we've had such a good move on contract labor. As you noted, you think about third quarter this year at 4.6% of labor cost for contract labor. It was 5.8% third quarter last year, it was almost 10% in the height of COVID. I think that we still have some room for opportunity there in '25, but not at that same scale of improvement, but we're working on that hard. But I would say, generally speaking, we're expecting, based on what we can see here today, decent stability in our operating platform. The exception you always have to watch for is changes in policy out of the federal government, right? So like the one on the cost side that we're watching carefully is tariffs. And so we're going to continue to study that. I don't -- I feel good about where we are positioned for tariffs in '25, but that would be an example of something that we are watching outside of just the normal construct.

And have you thought about a way for us to construct like how significant that could be, for instance, if there was a tariff put in place, what percentage of your costs you think that could apply to?

Well, remember, we navigated this during the first Trump administration, too, right? So we have some experience with that. I would say 3 things that as we think about this, this whole tariff thing. The first is what countries are targeted at what degree so that we got to kind of watch for that. The second would be do health care products get excluded. And often in the past, healthcare-specific products do get excluded from tariffs. So we're going to have to watch for that. I think that's a meaningful variable. And then third, and this is just kind of part of our contracting work with our HealthTrust group purchasing organization. The vast majority of our contract spend for 2025 is locked in firm pricing. So we feel good that we have good protections in our contracting mix for '25. So there's some risk there. It's on the margin. We're going have to see what happens, but it's an example of when we're watching.

Got it. Maybe you think about like supply costs or what? 15% of total maybe like is it 1/3 that's tied to tariffs?

Well, again...

I mean if you just look back to 2016, let's say.

You've got to answer those original questions, which countries are targeted I mean, there's a fair percentage of supplies that come from global sources, right? You can envision that and so there's a lot of nuance around which countries are targeted and whether health care products are excluded before you can get into the math of what's exposed.

But maybe I'll just ask then what -- before I move on to another topic I promise. Any 1, 2, 3 countries that you'd say like are the ones to watch?

China.

China. Anything beyond China?

Southeast Asia generally. But again, just like you, we're going to have to see the tariff policy that comes out of what was discussed in the campaign versus what gets implemented. So my sense is they're going to use tariffs as to negotiate trade deals. And so we -- I don't know that we have better information than you do about what the actual result of tariffs comes out, but that's what I would think.

Got it. Maybe just to wrap up on the volume side, right? A couple of things. One, do you -- when you talked about the quarter and the growth being closer to 3% to 4%, you talked about exchanges, which I think makes a ton of sense, right? The growth there has been phenomenal. You also talked about Medicare. Anything beyond 2 midnight, right, that you're looking at Medicare saying, here's where the growth is in Medicare that's driving that above average?

Yes, it's a good question. I mean, Medicare on the 2-midnight rule is actually a bit of a drag in '25 versus '24. I mean we've seen about 50 basis point growth to our admission count in '24 versus '23 just from that implementation of the 2-midnight rule and that doesn't repeat in '25. So that's actually a bit of a year-over-year drag on volume, on emissions. When I think about Medicare, what the projection showed is interesting is that we're in a bit of a cycle here of above-average aging into the program. So if you look at the number of people who are aging into the Medicare program in '25, it's above average growth than a normal pattern. And I think it reflects the baby boomers, who are hitting retirement age, hitting 65 and starting to join the Medicare program. So if you just look at those forecasts for really '24, '25, '26, you see a few years here, they're a bit above average in terms of people joining the Medicare program.

Got it. we need to wrap up there. Mike, Frank, I really appreciate your time. Thanks, everybody. We'll wrap it up. Thanks.