Universal Health Services, Inc. (UHS) Earnings Call Transcript & Summary

Good morning, everybody. Thanks for joining us. JPMorgan Healthcare Conference, continuing our health care services segment. My pleasure to introduce Universal Health Services, one of the country's largest for-profit hospital organizations, operating both acute and behavioral health facilities. As of the third quarter, 356 inpatient facilities and 41 outpatient sites of care with just slightly more than a 50-50 skewed towards acute versus behavioral. And it's my pleasure to introduce the Chief Financial Officer of UHS, Steve Filton. I think Steve is going to do some slides, and then I'll come back on and lead the Q&A session. So Steve, welcome, and I'll let you take it away.

Thanks, Gary. So what everybody has is of our sort of traditional investor slide deck. And I think for people who are particularly not familiar with the company, it's a useful piece of background information, and I encourage you to go through it. But for the most part, I'm going to really just try and talk through what has been for everybody, but particularly for health care providers, an extraordinary year. What's happened, where we are and how we're thinking about the future, do that all, hopefully, pretty concisely and efficiently in 20 minutes or so. And then I think it will be a good way of introducing the Q&A session, and we'll probably then be able to provide more color and expand on some of the things that we talked about. So I'd encourage people to look at first, just on Page 4, that kind of breaks out the company's businesses, and Gary did that in his introduction as well. And let me just go back now and talk about, I mean, the year began, meaning the year 2020 began quite bullishly for us or on a bullish note. We were pleased with the volumes and the demand in both of our business segments, and 2020 was feeling like it was going to be a very good year. And then in mid-March, we began to see our first COVID patients as to the hospitals around the country. And it had a terribly significant impact. Interestingly in retrospect, not because we were seeing so many COVID patients, but because our non-COVID business was dramatically impacted almost overnight in that sort of mid-March time frame. And we saw this terribly dramatic decline in things like our acute division, emergency room visits and elective procedures and surgical procedures, patient days in our behavioral business, patient days. Basically, as the entire country sort of began to adopt these very restrictive shelter-at-home practices, people were not leaving their homes, they were not traveling, they were not seeing doctors even in their offices. They were not going to hospital emergency rooms. They were not seeking help for mental health issues, and we saw dramatic declines and probably in that first couple of months, I would say, mid-March to mid-May, we probably lost a couple of hundred million dollars of EBITDA just as an estimation from these dramatic declines in volume. And even though we were trying to reduce and modify our expense load in reaction to that, we just weren't able to do it quickly enough. Now the government recognized and Congress recognized that hospitals were experiencing this dramatic pressure on their earnings and their ability to deliver care. And quickly in the beginning of April began to pass the first of a series of what were called CARES Act to provide relief, not just to hospitals, but partly to hospitals. And we received and recognized about a couple of hundred million dollars of those CARES funds in Q2, offsetting, to some degree, the other losses and EBITDA declines that I described. Things began to return to normal, I would say, early in May, and certainly by mid-May, we started to see elective surgical -- elective and scheduled surgical procedures come back, we started to see behavioral volumes rebound. And by the middle of June, we're feeling like we had returned almost to normal, if not, exactly to normal, something certainly within shouting distance of normal pre-pandemic levels. The one exception being emergency room volumes have never really returned to anything more than about 75% or 80% of pre-pandemic levels, but virtually everything else had returned to normal. And then right around the end of June, the beginning of July, we began to experience a second wave of COVID in most of our hospitals that, quite frankly, was much greater than the first wave that we had experienced in the March-April time frame. Because we have been dealing with this for several months now and because the government, both at the federal and state level, have grown more confident in hospitals' abilities to deal with the COVID patient levels, the second wave was far less disruptive than the first wave. And that's because we just didn't see this dramatic decline in other non-COVID business that we had seen in the March-April time frame. We didn't see that in the summer in the third quarter. And so while elective and surgical procedures had dropped by 50% or 60%, in some cases, 70% in the March-April time frame, in the July-August time frame, maybe they were down 5% or 10%. Not great, but certainly not anything nearly as traumatic as we saw earlier, and behavioral volumes, which had dropped to 80%, 85% in the March-April time frame of pre-pandemic levels, were now at 90%, 95%, again, not perfect, but not nearly as traumatic. And then UHS experienced an event that was unique to us and was not reflective. I think, everything else that I described so far was pretty typical of what most other hospitals had experienced. But in very late September and into October, we were the victim of a pretty significant cyber attack that really created a significant amount of disruption to our facilities. Most of our systems, while they were never compromised, they were never unavailable, they were never had their data exfiltrated, anything like that. Our ability to access those systems through our normal laptops and desktops and other devices was severely limited for several weeks. And as a result of that, we saw a decline again in some of our volumes that was non-COVID related. Ambulance drivers were going to hospitals where they felt like they wouldn't have to go through a manual admission process. And surgeons were going to hospitals where they wouldn't have to go -- their patients wouldn't have to go through a manual registration process. That lasted for, again, 3 or 4 weeks, I would say, by the end of October, we were again pretty much back to normal. But it's a disruptive element in our fourth quarter that most of our -- not most, all of our peers will not necessarily have that same experience. So then we get back online, we're feeling pretty good about being back in the saddle again in November and by the end of November, as has been widely reported, I think, as a result of the holidays and the winter weather, et cetera, we now begin to experience a third wave of COVID in virtually all of our geographies that, quite frankly, is more severe than either of the first 2 waves. And feels to me, something in terms of its impact, somewhere in the middle of that first wave, where there was a lot of government-imposed restrictions on elective surgery and these very dramatic shelter-at-home restrictions in many of our geographies, too and somewhere between the middle of that impact, which was quite severe, and our third quarter experience, which I think we would largely describe as having learned to manage through the COVID crisis. And that's where we sit today. We've got a very elevated level, more COVID patients in most of our hospitals than we've had at any -- other point in time in the earlier virus environment. We've canceled some elective surgeries in markets, literally on a day-to-day basis, depending on the other requirements of our demand. But we are pretty optimistic that once the holidays have passed as they have and once people get back to maybe a little bit more rational social distancing and behavior, and certainly, as the vaccine is more widely administered, we will see less of an impact as the year goes on. And I think we have begun to think about the second half of 2021 is looking much more normal, much more like the 2019 that we exited pre-COVID than anything that we experienced in 2020. And so again, in a broad sort of way, that's sort of a thumbnail sketch of where we sit. I'm going to go through a little bit more of the formal presentation now that I've provided that context and just talk a little bit about some of the other fundamentals of the company that maybe we can explore further in the Q&A. If you look on Page 5, our investment highlights. Gary talked about the number of facilities we have. It's a pretty diversified revenue base with some concentration as people who follow the company now in Las Vegas, and I'll talk a little bit more about that in a second. We've got a history, a very disciplined balance sheet management, a history of being a fairly low levered company. I think that held us in good stead as the pandemic began. We never felt like we were facing any sort of dramatic shortfalls and cash flows, et cetera, that we couldn't deal with. And as a matter of fact, and you'll see a leverage slide on Page 9, you'll see that our free cash flow actually increases by a dramatic amount during the pandemic, mainly because of the government funds that we've received, some of which will ultimately be returned to the government. Page 6 talks about some of the specific markets that we have, particularly from an acute care perspective, and I'll talk briefly about Las Vegas because people seem to focus on that appropriately so. I would say the dynamics in our Las Vegas market are no different than broadly the dynamics that I've described here in the first few minutes of my presentation, but I will say this, that, that market has probably been harder hit than most. It has an unemployment rate that is higher than most other markets, and it's kind of been the low teens and the last thing I've seen low-double digits, mainly because, obviously, the gaming industry has taken a severe hit, particularly from airline travel and international travel. Interestingly, the feedback that we get is that like on the weekends, the casinos and the gaming properties are required to operate at no more than 50% of capacity. But on most weekends, they operate at those levels. And that's just really from local folks, meaning people who are from Las Vegas or from Arizona or from California, who are visiting the casinos by driving their -- the amount of airplane traffic, both domestically and internationally, is still well, well below pre-pandemic levels. Although again, I think all the comments that I made earlier that as the levels of COVID patients ease and as the vaccine is more widely administered, we would expect those things to -- in that economy to get back to normal on a relatively accelerated basis. Page 8 talks about revenue and payer mix. We really talked about some of the pressures on our revenue and volumes. But I will say from a payer mix perspective, we haven't seen a tremendous -- we've seen a slightly higher level of uninsured volumes. But what I think we are finding, at least, in the early stages of the pandemic and the recession that is, I think, caused by the pandemic that we're not seeing dramatic changes to our payer mix. And I think that's consistent with what our experience has been in prior recessions that payer mix deteriorates with higher unemployment, but it takes time, and it happens over an accelerated -- excuse me, an extended period of time rather than immediately for a variety of reasons. In this case, I think larger employers tended to not just terminate workers at the beginning of the pandemic but furlough them. They kept their benefits even if they were not getting paid a salary. We know that some of the larger employers in Las Vegas, that's emblematic, and there's still -- many of their employees are still having their benefits intact and in place. Employees also are able to -- excuse me, in some cases, access COVID -- not COVID, COBRA benefits, we see that dynamic. And also, we're obviously in this recession in a post-ACA world, so there's Medicaid expansion in a number of our states like California and Nevada and Washington, D.C., that helps to ease, I think, the unemployment burden on hospitals. And also, obviously, the availability of subsidized government exchange products, I think, has helps to do that as well. So again, at least currently, not seeing dramatic decline in payer mix, although over time, I think we'll see more of that if unemployment remains at elevated levels. Beginning on Page 14, the slide presentation begins to talk more specifically about the 2 business segments. Let me just comment very quickly on our Behavioral business. Some people, and I think to some degree, we internally were surprised that the pandemic has had as big an impact on the behavioral business as it has in the sense that we're not really treating COVID patients, we're not treating them for their COVID illness, certainly in our behavioral facilities. But what we have found is that a few dynamics have muted some of our behavioral revenues and volumes. One is with acute care emergency volumes down, that's had an impact on our behavioral business. Many of our acute care behavioral hospitals rely on hospital emergency rooms as a significant source of referrals. So reduced ER traffic has had an impact there. The fact that schools were out and in many cases, even to the degree that they've returned or not in person, seems to have had a measurable impact on our adolescent referrals. The reduction in travel has certainly impacted some of our more programs that have a more national kind of reputation where people are traveling for significant distances to get care. So that's been an issue. And then the sort of the mere presence of COVID patients in our behavioral hospitals has often rendered our ability to take care for our total patient population more inefficient than we are on the acute side, meaning in our acute hospitals, we've got in our average acute care hospital today, maybe 100 COVID patients, and that means that we've dedicated floors and wings to them, and we're doing that pretty efficiently. On the behavioral side, we tend to have a handful of COVID patients in a facility and that generally means that we're shutting down beds. We've got 2 or 3 patients in a 20-bed unit, and we've now shut down the whole unit. So it's not to expose other patients to them, which leaves us with 15 or 16 empty beds, and it's inefficient. And then the other issue, of course, is that we've got, at any point in time, a significant number of our employees who either have the virus, which they may or may not have contracted in the hospital, I think, in more cases than not they've contracted outside the hospital or they've been exposed to the virus, again, in many cases, outside the hospital. But the impact or the bottom line impact is the same. They're being quarantine, they're unavailable to work. And that has limited our ability to treat as many patients as we'd like to treat. I have just a couple of minutes left, trying to stick to my sort of 20 minutes, and I'm going to direct people to the acute care segment, which begins on Page 19 and just make some very, very quick comments about our acute care business. What we experienced in Q3, especially was we saw this decline in volumes, which I mentioned, driven by lower ER volumes, driven by people deferring care, et cetera. But it was offset in large part by higher acuity, the patients that we were seeing in the hospital who were either COVID patients sicker than the average medical patient, the patients who are staying away from the ER tended to be the less acutely ill patients, et cetera. So we saw this sort of natural shift to higher acuity which was largely offsetting some of the lower volumes. I suspect that higher acuity will persist into Q4, I'm sure it will. But the exact sort of relationship between higher acuity in volumes, I think, remains to be seen, given the fact that the levels of COVID patients that we're experiencing in Q4 are, as I said earlier, much more elevated than anything that we saw in the first 2 waves earlier in the year. I'm going to stop there. I'm sure there are a bunch of things that we can explore in greater detail, questions that Gary or others might have, but I think probably the most effective way at this point is then to just pause and answer those questions.

Great. Thank you very much. Just as a reminder to folks that are watching the video, directly below your video player is a blue button, where you can submit a question to the queue, and I'll do my best to try to hit some of those as we're talking to Steve. Steve, good recap of maybe the most complicated year in your career in health care, I'd suggest. Maybe a couple things you mentioned, I just want to touch on. When we think about some of the disruption from the cyber attack, which was either late September or early October, I guess, really, that impact wasn't felt in the third quarter, the impact of that would be in the 4Q. And I know it didn't take a lot of time for you guys to get that resolved. Is it -- do you have line of sight to think about that as something material sequentially versus third quarter? Or with all the other sort of moving parts in the 4Q, you wouldn't isolate that as something that could be material to the quarter?

Yes. So I think, Gary, it will wind up being a material item that we will sort of separately call out and identify one of the challenges, and you've never -- I think, intellectually, you know that we're very reliant on our information technology, but you don't really realize how much you are until something disrupts that. And so one of the challenges we've had is doing sort of a precise calculation of exactly how much we were impacted because we were delayed in our billing and our coding, and we're catching up on all those things. And I think, certainly, by -- actually, by right around now and certainly by the time that we report our fourth quarter earnings at the end of next month, we'll have a much better handle on what that impact was. But I think it will wind up being a material number. No, I don't think it's a recurring number. I don't think it really has any ongoing impact. But we'll be in a position when we release our fourth quarter earnings to say this was the impact from the cyber attack. This is the impact from higher levels of COVID, maybe from lower levels of elective surgeries, we'll be able to parse all that out and then talk about the assumptions that we're making for 2021 in regards to all those things. But I think in terms of the cyber attack, that's easy to say that we obviously don't expect any sort of ongoing or lingering impact from that. But I do think it will be material.

Okay. And when we think about Las Vegas as your largest market, I'm not sure you've ever really talked a whole lot about payer mix in that market, but maybe I'm wrong. But in my mind, I kind of perceive that to be a little more skewed to commercial. Is that a fair characterization or...

I think in the end, our payer mix in Las Vegas is not terribly different than it is sort of across the portfolio for a variety of reasons. Number one, we do get a small amount of our business from the gaming industry and the travel industry, people who are in Las Vegas and wind up having to seek medical care while they're there. And that's generally a very good sort of commercial payer, but it's a relatively small amount. I mean 90% to 95% of our patients in Las Vegas are locals and not people who are visiting the city. Las Vegas is also a very big retirement community. People retire there because there's no income tax, and it's a pretty moderate temporary climate, et cetera. So there's that aspect to it. So in the end, while I think there are reasons why it skews slightly to commercial, it also skews a little bit to Medicare. And so I think in the end, the payer mix doesn't look terribly different than it does elsewhere.

And one other thing that you touched on was just kind of the furloughs and the fact that a lot of employers are still maintaining benefits, despite the jump of unemployment that we've seen nationally that you've seen in Las Vegas, most providers and most commercial health insurers haven't nearly seen the rate of decline in commercial enrollment or commercial peer mix on the provider side. But everyone is suggesting that, that is likely to come that the furloughs ultimately, to some degree, are likely to turn into layoffs and loss of benefit. How would you have investors thinking about that? At this point, should we say, let's see what the Democrats do, let's see the extent of the stimulus bill and additional paycheck protection and other things that might be forthcoming? And really until we have that, it's going to be really difficult to have sort of line of sight on when that possible deterioration of mix could play out? Is that your primary variable, you think, at this point?

Yes. Well, look, one of the things I would do is remind people and to the degree that they're able to, they can go back and look at our experience, and I think the experience of the industry, in general, back in the sort of 2010, '11, '12 time frame when we were experiencing the impacts of the Great Recession. We went through several years where unemployment rates nationally were at 10% plus. In some markets like Las Vegas, they increased to something like 15%, I think, at their height. And what we saw in that period was, number one, over an extended period of time, it didn't happen overnight. We saw our payer mix decline and the way that, that sort of manifests itself is in a lower revenue per patient day base per adjusted admission is probably a better way of measuring it on the acute side. But I want to sort of reinforce the idea that it's sort of an incremental change. We went from revenue per admission growth pre-recession in 2008/'09 of 6%, 7%, 8% to revenue growth during the recession in '10, '11, '12 of 3%, 4%, 5%, not an insignificant change, but not the kinds of wild changes that we've been seeing during the pandemic, which is really affecting volume much more than it is affecting payer mix. So my sense is, and I don't know that we're any smarter about this and how quickly the recovery will take place. I think one of the reasons back to, I don't want to mix too many metaphors here, but one of the reasons why a lot of these large employers have furloughed employees, kept them on their payroll per se with benefits is the notion talking about Las Vegas specifically that once we have a vaccine and once it starts to be widely administered, the market will come back relatively quickly, and they're trying to keep these people, their employee labor force engaged as best as they can. And so we'll see. I mean I'm not smart enough to know exactly what the cadence of this is going to be, but the sense is there will be a recovery. But yes, look, I think one of the things we will look for is sort of on a same-store basis, revenue per admission will probably decline in 2021 as compared to 2019. Because some of this acuity and stuff will stay in place and we'll have to deal with that. And back to your comment, I mean, this is sort of a more complicated dynamic than we faced in some time. But I think broadly, it would be sort of disgenuine of us to think that there wouldn't be some impact from higher unemployment. We've always seen that. And I think we will see it, but I just remind people that, that tends to happen over an extended period of time.

And how do you think -- one of the things I think has really been misunderstood about the hospital industry in past economic cycles, investors rightly, to some degree, you get really worried about commercial mix; to some degree, they get worried about volume; to some degree, they get worried about bad debt and collections. But the industry's EBITDA has been extraordinarily resilient typically because there's this great sort of countercyclical benefit on the labor side, usually, in a weaker economic environment, the available supply of clinical labor expands and you get some benefit on your cost per FTE. Is that plausible heading into next year when we read so much about the clinical burnout, just from the load and the stress that your nurses and other clinicians have felt because of pandemic? Or do you still see -- or maybe just tell us what you're seeing in terms of labor rates on both sides of the business? And are we seeing that sort of historic countercyclical benefit?

Yes. So -- and I would add to that. So I think, first of all, everything you said, Gary, is accurate and true. But I would add to that I think UHS historically has been -- has had even a further countercyclical sort of cushion because I'm certainly looking at the last recession, the behavioral business didn't face sort of -- some of the same dynamics as acute, particularly as it related to any volume pressures. So I think on the acute side, what we saw is that emergency procedures tend not to be impacted by a recession. But elective procedures might be. People lose their jobs, they lose their insurance, they might defer or postpone procedures, et cetera. On the behavioral side, one of the things we find is that people who are making kind of the admission decisions are often not the patient themselves, and they're certainly not being made on an economic basis. So if a school system identifies a child in need, they're really pushing that -- military base is pushing their soldier to get care. And again, we're talking about getting care. We're talking for people who are really deemed to be a threat to themselves or to others a very sort of dramatic kind of an event that usually results in an inpatient admission of behavioral. But in any event, if you go back and you look at our behavioral revenue per adjusted day back in the recession, it was far less impacted than on acute set, so that's another kind of a cyclical piece. The fundamental point that you were making is sort of true that normally, as unemployment goes up, we see actually an increase in the supply of labor hours. I'll use the sort of anecdotal example, but I think it gets repeated in a real way. A nurse has a spouse who loses his or her job. And so now she goes from working part time to full-time or I often say she, although plenty of our nurses are males or they work an extra shift or retired nurses come back and work a couple of shifts for the same reason, all those sort of things take place. We don't see that impact or have not seen it in the early stages of the pandemic because offsetting that, not so much the burn out really. I mean I think that's real, and there are some nurses who've just sort of said, "I can't work in this environment." But it's really more the virus itself. Nurses get the virus, and now they're on the sidelines for 2 weeks. Or in a lot of cases, they're exposed to the virus and they're now on the sidelines for 2 weeks because they're being quarantined. And not that it matters, but I will make the point that, I think, in many cases, they're getting the virus or exposed to the virus, not in the hospital but outside in their personal lives, the ultimate bottom line impact is the same, it doesn't matter. But I think that's why we have a point of view that the reduction in COVID cases that comes as a result of the holidays passing and especially now the vaccine being administered, really helps the hospital industry in 2 important ways. One, it will increase the demand. People will feel more -- the general population will feel more comfortable about getting out, getting to the doctor, getting to an EOR, not postponing procedures, et cetera, once they've been vaccinated. And two, our ability to meet that increased demand will be much greater. And back to your point, some of the pressures that we've seen on our labor hours and labor supply will be diminished because our -- we won't have nearly as many employees out on the sideline.

I want to go to a couple questions we've had online. The first one is a question I also had, but there's a nice addendum to it. It's around the price transparency regulations that are essentially in effect. Now -- where you're required to post your commercial prices from commercial payers. So my question is, what impact, if any, do you think that has on your business, either your volumes or your ability to negotiate rates with payers, but the client more explicitly says, are you compliant with that regulation today? And where can we find the data? Presumably, I would imagine it would be the hospital by hospital local website, but I'll let you talk about that.

Yes. So first, the mechanical answer is, we are compliant. If you go on any of our hospital websites, you'll see that data out there. As I understand that, and again, it's a pretty busy time with lots going on, so I certainly haven't had the chance to validate this. But I think some of our peers, some other hospitals have not been fully compliant, and I'm not sure what the implication of that will be over the long run. But yes, we are fully compliant. What the impact is going to be? I will tell you, Gary, is a matter of some debate internally, and I'll give you sort of the different points of view. My point of view is while that information has not been sort of perfectly known and sort of perfectly out there, I feel like it is largely known. Again, I'll use Las Vegas as an example. Our biggest payer in Las Vegas is virtually, I think most people know is United/Sierra. As a consequence, they have our or pay us the lowest rates in the market. As you know, you would expect our largest payer to do in any market, we're not disclosing their specific payer amounts. But if somebody comes to us and says, which is entirely possible. "we know what you get paid from United, we want that same rate." Our response is always, "Okay, if you give us the same volume, we will we pay you -- we will accept the same rate." And that's just going to continue to be true. So my view is that this is going to largely be much ado about nothing, the broad out parameters of what providers are getting and payers are paying is largely known, and there's not going to be a lot of new information. Now I will tell you that we have some folks in our managed care sort of function that worry a little bit about payers seeing and having more insight into the data that they've previously had and sort of worried about them putting pressure on us. And I suspect there'll be instances of that. At the same time, I think, we have a point of view that now we'll be able to go on to our competitor websites and see the same information, and in some cases, be able to react to it. But again, I'm going to come back to my sort of fundamental view, which is while the absolute precise data hasn't been out there before, I think broadly, both the payers and providers had a pretty good sense of what the market was like in every single geography. And so my sense is there could be some incremental impacts in particularly geographies, but I don't think it's going to be a real new.

Yes. I tend to agree. It certainly doesn't change the underlying inherent supply-demand dynamics in those markets. What about the other side of it though, consumers theoretically can see this information for the first time. I think that's from the CMS innovation center view, I think, they perceive that to be the primary benefit. Of course, the consumer's exposure is limited to their co-pay, deductible and how much they've achieved and hasn't achieved. So the full weight of a pricing differential never gets felt by the consumer. And it's not obvious that consumers are extensive price shoppers for hospital services when their physician or surgeon directs them somewhere. So we've debated how much of a price differential actually felt at the Pocketbook level, would a patient have to feel before they tell their physician or surgeon, "no, I want to do something of somewhere else." Any quick thoughts on the consumer side?

Yes. So look, and I've, again, made this point a lot and believe it strongly. I don't think people shop for health care the way they shop for a car or a refrigerator. And I don't think that's going to change whether or not the data is out there. And I give a personal example, but I think it's very relevant. Look, I'm probably, in theory, it's sophisticated health care consumer as anybody. Years ago, my wife needing elective MRI and I -- at the time the data wasn't out there, but I just called around the hospitals and basically shopped for the best price and got it. And got the hospital to waive any co-pay or deductible that I had. I would say that 90% of consumers don't even have that level of sophistication, and I won't say that really in a derogatory way, it's just factual. They're not going to do that, but you can do that. But a number of years ago, my mom was in a car accident and in the hospital for an extended period of time. And I just did whatever the hospital -- the doctor and the hospital told me to do. And the bill was enormous, and I wasn't shopping around, and I wasn't going to move my mind. It just is what it is. And I think that the bulk of the hospital expenditures, in particular, fall into that category where they're large and they're complicated and in many cases, their emergencies. And the last thing that patients are going to do is comparison shop. And by the way, even when they choose to do that, it's a pretty complicated exercise. And it's not like when you're buying a car, and all you have to do is input this model, this year, these extras, and now you get a print out and you walk into the dealership. And you hand it to the salesman and you say this is what I'm willing to pay. Health care, in general, just does not work that way. And maybe I don't think it's going to happen in my lifetime, but maybe we get to that point sometime, but it's not any time soon.

And then sort of our closing minute here, there was a question about restarting your share repurchase and dividend program. You had alluded to your cash flow strength and balance sheet strength. I don't imagine you're going to disclose on this call the specific date that you're going to reinitiate those activities. But help us understand how you think about it. Do you need to see the virus dramatically receded? Do you need to see vaccine? Are there other financial metrics? What will go into your thought process as you decide?

Yes. So first of all, I think in terms of time frame, we always thought that our fourth quarter earnings announcement, which will be the end of February, would sort of be the right time. And I'm not going to sort of say definitively it is or it isn't at this point. I think the way you described it is right, Gary. I mean we would hope that even 6 weeks from now, that there'll be a lot more sort of certainty surrounding sort of the environment. And while it's entirely possible, and I'm sure probable that the bulk of the population still hasn't been vaccinated. At least at that point, there'll be more visibility to when that's likely to happen. But I think we're all feeling more comfortable that this is more -- that by the time we get to the second half of 2021, it's going to look a lot more, I'll call it, normal pre-pandemic, like 2019 and 2020. And so I think in relatively short order, whether it will be the end of February or a few months after that, we're going to be prepared to resume a much more normal kind of capital deployment flow because I think that level of confidence will be out there, if not in 6 weeks and -- or 8 weeks or 10 weeks. I mean I don't think it's quarters and quarters away or certainly not years and years away. I think we're talking about weeks and a small number of months.

Great. And with that, we're out of time. Thanks so much for joining us for UHS, and everybody, have a great day.