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

Thank you, everyone, for joining us today. I'm Ben Hendrix, Healthcare Services and Managed Care analyst here at RBC. Very pleased to have management from Universal Health Services join us again this year. We're hosting Steve Filton, Chief Financial Officer. Thank you for joining us today.

My pleasure.

Yes. I just wanted to start the conversation with the obligatory policy bring down. Of course, we have the House Bill moving along, and it seems like work requirements are in play for Medicaid policy, but maybe we're grandfathering in some DPP programs. Just anything you're seeing that strikes you or changing in your thoughts there?

No, I'm sure our reaction is similar to most investors and observers in the industry, and that is to think that the negative impacts potentially of the bill are less dramatic in draconian perhaps than some thought could be. The work requirements I think we always knew were coming. I don't know, it's hard to say exactly sort of what the impact will be. I will say that this idea that the work requirements obviously are targeted at generally this Medicaid population of younger, healthier males. I'm not sure that, that's the population that makes up the bulk of our hospital utilization. So again, I'm sure there will be some impact, but I don't think it's as sort of obvious in terms of just the overall numbers. And then I think the impact on these direct-to-payment programs, which I think were a very significant focus and concern going into the sort of legislative negotiations are -- clearly, it appears what the intent of the Republicans in Congress is to really limit the growth in these programs, the new programs, the growth in the existing programs, et cetera, which certainly has an impact. But again, appears as if it will have little impact on our existing programs and the existing cash flows, which again, I think is encouraging.

In that vein, we talk about the DPP programs and kind of limiting growth. Do you believe that there is ample recognition of the importance of these programs as a critical part of Medicaid funding, or do you think there is still will in Congress for kind of deeper cuts and kind of curtailment of these kind of back to maybe even kind of pre-Trump level?

We always had thought that these programs were very positively embraced by the states that had implemented them, and that included any number of states, certainly, in our case, places like Florida and Texas and Mississippi and Idaho, very red states, and that those state governments, their legislators, governors would lobby hard for the need and the sort of effectiveness of these programs, and I think that has had an impact. So to your point, is there still an appetite on some in Congress to do anything further? The answer is yes, I'm sure there is for some, but you see how much the Republicans are struggling to pass this one bill. It's hard to imagine that there's a lot more that gets done beyond this.

Got you. And I know that top of mind right now from a program perspective is Tennessee across a number of companies in our coverage. And for you is Tennessee and District of Columbia together? I think you've quantified that in the 150 to 170 range, maybe 6% to 7% upside to your guidance. My understanding is the Tennessee is largely approved. We're waiting on the 1115 funding mechanism. Is that your understanding as well? Any developments from there?

It is. And I think most people are of the view that the Tennessee program, even though the 1115 Medicaid waiver is still forthcoming or to be forthcoming, would be grandfathered under sort of any reading of the current bill. The D.C. program, I think, is more of a question mark, a bit of a toss-up at this point. It's been submitted to CMS for some time. The District of Columbia, the Health Department believes it will get approved. Whether it will get approved in time or a time frame that it would be considered grandfathered under the bill is I think an open question. But Tennessee, I think much more likely.

Is there anything specific about the 1115 construct for Tennessee that's making it take a little longer than others in your mind?

Nobody seems to think so. And I think the general view is that if CMS had any real problems with the program itself, they wouldn't have approved it, knowing that they had an issue with the 1115 waiver. And so I think the notion is it's just part of the pipeline of approvals that CMS has to get through.

And then with the grandfathering, I mean, we did see cash flow from Nevada, I believe, in the first quarter. Anything in there that strikes or gives you more or less comfort in the bill over existing plans like Nevada being maintained at their current levels?

No. I mean we were encouraged, a, by the -- it's actually interesting. The chronology of it is that CMS directed the state originally, even before the program or the expanded program was approved to make those payments, which we got in April, and then they did approve the program. And I think we just broadly and partly because of how important Nevada is to us, viewed that as, again, just sort of an overall sign that CMS was prepared to approve these programs in the normal course and that the pipeline of programs remaining to either be reapproved or newly approved would continue. And so I think to me, or to us, I think the remaining question is simply as those approvals come and particularly the new approval and particularly D.C., how is it going to fit within that grandfathering language that's in the bill.

That makes sense. And then any thoughts on if these reapprovals will have kind of normal course inflationary constructs to cover the cost of rising labor or what have you?

Yes. So I think that's an open question. Again, clearly, it appears to be -- the congressional intent is to cap the growth in these programs, but whether that's on a sort of percentage of provider tax or an absolute reimbursement amount, et cetera, I think, is still an open question.

Got you. Moving on to volumes and your segment performance. I think you came out with expectations for the acute segment volumes to kind of grow within long-term targets. I think some of your peers have talked about long-term targets maybe plus 100 basis points or so. Just wanted to see what you're seeing kind of thus far through the year and if we're still kind of on track to hit that long-term growth trajectory.

Yes. So when we gave our original '25 guidance at the end of February, we talked about our acute care same-store growth rate target being in that 5%, 6%, 7%. And I would believe that, that's relevant not just to '25, but to kind of a longer-term target. So if you pick the midpoint of that 6% and say, we said it would be split pretty evenly between price and volume. I think we were on the low end of price and volume in Q1. I think that's a function of the comparison to a leap day last year and I think a slightly muting impact of the flu season in terms of acuity and pricing. But I think those seem to be very achievable targets for us. And I think for our peers, we all kind of, I think, put up volume growth numbers in Q1 that were pretty similar. So yes, that feels like, a, a more normative kind of recurring sort of target coming out of the pandemic, but certainly sustainable and achievable going forward.

And on the behavioral side, we maybe saw flattish volumes in the first quarter, so maybe implying a little bit more of a ramp through the latter part of the year. You noted having seen some volume accelerate in late March, but I know that we've got a calendar day headwind in April. So now that we're kind of getting through May, anything kind of showing you any different trajectory than what you were expecting?

No. I mean I think it's, from our perspective, an upward cadence. Obviously, this was probably a more focus on the Q1 earnings call and then subsequent sort of conversations with investors. I was fairly emphatic -- or we were fairly emphatic about the fact that our 2.5%, 3% patient day growth target was still intact. That was still our target for the year, got a lot of attention, got a lot of questions. I would add that I also said on the call that if we didn't achieve the target, the volume target, I thought that we would still get to our overall revenue target, because I think our overall behavioral pricing would be stronger than our original guide. And I think that's still our view. We've seen an upward cadence in our volumes. I think they will improve. Whether we'll be able to get to that 2.5%, 3% for the full year, I think it is an open question, but I think whether we do or we don't, we're still going to get to our overall revenue target for the year.

And maybe you can talk a little bit about the pricing trends in behavioral have been very strong. And as you say, they're kind of carrying maybe a little bit of softness on the volume side. So what kind of trends are we seeing there? And what kind of cases are presenting?

Yes. And I think we made the point and have made the point, because that pricing has been strong for quite some time now, that there is, I think, a real interplay between volumes and pricing on the behavioral side, and that is as it's been -- as I think capacity, overall capacity, both at our behavioral hospitals, particularly our acute behavioral hospitals and the industry has been somewhat limited either by labor scarcity and the ability of providers to fill their vacant positions by physical capacity, the number of beds available, those sort of things. It's given us more leverage over our payers to say, look, if you want to be assured of a bed or capacity for all your subscribers, you're going to need to pay us what we believe to be a market rate, et cetera. And I think particularly amongst our managed Medicaid payers, that's been kind of a potent argument and a relevant argument, and that's really, I think, helped us. And our view over the longer term has been, going back to if we're going to get to the 6% or 7% same-store revenue growth over an extended period of time, that has been skewed more towards price than to volume, as your question sort of alluded to. We think over time it will skew less towards price and more to volume. But that shift has been slower to occur than we originally anticipated.

Maybe we can touch on your referral relationships and what you're seeing in behavioral. Clearly, one of your competitors has seen some behavioral headwinds amid some company-specific headlines, but just wanted to kind of get an update on your referral relationships and how they've held up and any changes you're seeing in the market?

Yes. I mean I think our referral relationships continue to be strong. And obviously, those are market-specific and geography specific. So it really is dependent on the quality of care that you deliver, the, I think, effectiveness of your relationships and your communication with your referral sources, how your patients feel about their care and their treatment and their outcomes. All those things, I think, are important. And I think we generally do well in all those areas. I don't know that we've really had any significant -- we've enjoyed any significant sort of measurable impact from some of the struggles that our peer has experienced. We don't compete with them in all that many markets directly. But in the markets that we do, it's not been obvious to us that there's been a significant market share shift to our benefit. But just generally, I think we find that behavioral demand remains strong. And the challenge for us is meeting that demand, filling vacant labor positions, efficiently dealing with our referral sources, et cetera, because there definitely is more competition, I think, particularly given sort of the strong pricing, giving some of the benefits of DPP payments in certain states and geographies, we do see more competition in behavioral. And that means that all the things that I talked about, relationships with referral sources and efficiency in handling referral requests and communicating with, all those things become even more important because you're competing with more people to do that the right way.

And then as far as policy impacts behavioral, we've always seen broad bipartisan support for behavioral support and reimbursement updates and trying to expand access to behavioral health care. In the new administration, I imagine that's continuing, but then also like we've heard from Alex Azar, yesterday, there's been some shift in sentiment around various policies, whether it be Medicare Advantage or otherwise. Do you still see continued bipartisan support in behavioral like we've seen in prior years? Or is there anything shifting there?

No, I think your characterization is fair. And I think it's driven by the notion, which I think is appropriate, that again, demand for behavioral treatment is growing. And it's important, I think, to both parties that access to that care is available, et cetera. Look, I think there is definitely movement, both on the part of policymakers and legislators and the payers and employers to make sure that care is delivered in the most efficient setting, which I think means greater emphasis on outpatient care in its various forms, et cetera. And so we're dealing with that and I think expanding our outpatient footprint and outpatient continuum with partial hospitalization and intensive outpatient therapy, et cetera. But yes, I think, broadly, the crux of your question is, I think that broad bipartisan support that we've seen certainly, in recent years, seems to be holding steady.

Great. And before we move on to kind of talk about capital allocation and those topics, I wanted to jump back to acute care and just kind of get an idea of some of the volume across categories. I know we've got -- given some of this calendarization that we're seeing in the first quarter with day count and with April and the lapping past Easter, just wanted to get your thoughts on how we should expect trends in various acute categories kind of going through the rest of the year.

Yes. I mean, again, I think if -- we've talked about the acute care business growing 5%, 6%, 7% same-store revenue, if you pick the midpoint there, 6% sort of based on kind of 3% volume, 3% price growth, we were close to both of those targets in Q1. That seems to be the right -- or feels like a very achievable target on both sides, both price and volume. You talked about some very kind of nuanced sort of issues, the timing of Easter and spring break in Q2, whatever. But I think over the full year and honestly, over kind of a longer, maybe more intermediate-term period, that sort of 6% growth split pretty evenly between price and volume certainly seems to be quite achievable.

And then also I just wanted to squeeze in. You've kind of given your thoughts on the tariff discussion. I think in the past, you've said maybe 75% of your supply costs are fairly protected, which seems consistent with a lot of your peers, most of whom are involved with the Health Trust GPO. But since we've seen some kind of loosening of the tariffs against China, any changing thoughts in your overall impact there?

I don't think so. I mean I think you see in our financial statements that our supply expense has been well controlled. Clearly, there's been little impact to the tariffs in the short run. And I think our view is that any impacts in the longer run seem to be mitigated by kind of a less intensification of the tariff language and the threats, et cetera. So it feels like certainly in the short term, in '25 and '26, there's not a lot of threat now. Obviously, if we go back to an environment in which the country is treating tariffs with China and others much higher tariffs. I think there's a risk of the contracts that we have and the supply chain, the dynamics that we have coming under pressure, but it doesn't feel at the moment like that as significant a threat as we might have thought just even a few months ago.

Yes. And I just wanted to talk about capital expenditure maybe in that regard, $240 million in 1Q is tracking in line with kind of what you've put out for the year? And maybe you can break down how you're prioritizing CapEx this year? I know we get a lot of attention on this from our devices analysts, who are curious about what kind of forecast is for the kind of equipment you're acquiring for your facilities?

Yes. So I think in our case, it's worth noting that a good chunk of that $240 million, I would say, probably between 1/4 and 1/3 of it are devoted to these new hospitals that either we just have opened or are opening. So we have our West Henderson hospital, which although it opened in late 2024, there's still a lot of equipment purchases and things that went through or at least were paid for in the first quarter. We're building a new hospital in Palm Beach Gardens, Florida, that's consuming a significant piece of that. And we're building a replacement acute care hospital in Riverside County, California. So I would say of that $240 million, like I said, 1/4 or 1/3 of that is these new hospitals. Beyond that, I don't know that there's anything terribly sort of skewed in our spending. It's not based on any particular or skewed to any particular service line. It's not skewed more towards acute or to behavioral. We're building new behavioral beds and some new behavioral hospitals as well. And then we have our regular maintenance capital. But I think, again, in our case, our CapEx for the year is somewhat inflated by the new hospital projects.

And on the topic of West Henderson, it seems like you've seen faster-than-expected ramp there and maybe some early EBITDA contribution. Maybe you could kind of talk about performance to date there and kind of how that's trending.

Yes. So what we said on our first quarter call is that West Henderson was EBITDA positive in its first full quarter of operation, which is really extraordinary kind of ramp-up for a new hospital, although our experience with new hospitals in Las Vegas tends to be better, faster, et cetera, than in any other market, and West Henderson seems to be replicating that model or dynamic. What we said, again, in our original guidance, we have about 2 hospitals basically opening in 2025. West Henderson, which opened very late in '24, and then Cedar Hill in Washington, D.C., which opened in April. We said that the 2 combined would be modestly EBITDA positive for the year. I think that implies that West Henderson will be measurably EBITDA positive and Cedar Hill will be somewhat negative for the year, which I think is what you would expect in a normal hospital ramp-up. And that seems to be the way we're trending. Cedar Hill may have a slightly sort of outsized drag in Q2 as it opens with start-up costs and a slow ramp-up than any hospital has. But again, I think our overall guidance that we gave, which is that the 2 combined would be modestly EBITDA positive for the year remains our thought.

Probably safe to assume that kind of as a base case assumption at the Florida and California hospitals track closer to Cedar Hill in terms of their ramp-up trajectory?

Yes. I think, again, well, the California hospital is a replacement facility. So that's a little bit of a different dynamic. But the Florida hospital, which will open about a year from now in the spring of '26, I think the typical ramp-up for a new hospital is usually, it takes 12, 18 months to get to sort of, I'll call it, divisional-wide margins and averages. And I would think that generally would be the forecast for our Palm Beach Gardens hospital.

And how is staffing some of these newer facilities? It seems like it's gone fairly smoothly, but anything to observe on the labor front there?

No. Again, I think sometimes at a new hospital, you're obviously staffing from a blank slate and it can be a little bit challenging. And then I think as part of the challenge of the ramp-up, lots of orientation, some initial turnovers as people get used to the new facility, et cetera. But I don't think -- I think all those dynamics are expected and we've been doing this long enough that it's something like we know how to do, and it's not terribly disruptive.

Got you. And then more broadly on the cost side, I just want to go back to that for a second and talk about professional fees. We've seen some of your peers talk about a little bit of an increase kind of at the start of the year and just kind of what you're seeing there and how that's being managed?

What we said going into the year was that professional fees, which had seen a significant increase in late '23 and then well into '24, in '25 would increase by kind of just a normal inflationary amount, 5% or so. And that's really been the way it's looked in the first quarter, and I think it remains our expectation for the year. Some of our peers say, and we would share the view that we still feel pressure from some hospital-based physician providers. I think a number of folks -- the original pressure, I think, on those professional fees back in '23, '24 really came from emergency room physicians and anesthesiologists. We've talked and some of our peers have talked about radiologists being more recently sort of pressuring us. But it doesn't feel to us like that's going to be something that's really going to measurably affect our costs. Part of the benefit or the ease in dealing with radiology rather than some of these other services is there are other options for radiology. Radiology can be a service that is performed remotely. There have always been providers that provide sort of weekend and overnight services and radiology reads, some even foreign providers do that, as opposed to ER physicians and anesthesiologists who have to be there in person. So just more optionality in dealing with that radiology pressure.

Great. Well, I think that brings us to time. Thank you very much, Steve, for being with us.

Thank you. My pleasure.