Albert Rice

Albert Rice inquired about the seasonality of the $25 million-$35 million Stelara gross profit headwind for 2026, specifically whether it would be evenly distributed or if Q1 would be a tougher comparable due to 2025 forward buying. He also asked about AI applications beyond claims processing, such as clinician utilization, staffing, or inventory management.

Answer

EVP and CFO Meenal Sethna stated that the $25 million-$35 million Stelara headwind for 2026 is expected to be fairly evenly distributed, without the Q1 phenomenon seen in 2025, though the year-over-year Q1 comp will still be tougher. President and CEO John Rademacher detailed AI applications in call center capabilities, workforce optimization, and inventory management, noting that these tools augment the team's efficiency and quality. He clarified that AI is not yet used for clinical protocols but may support clinicians in areas like note capture.

Albert Rice asked for clarification on the seasonality of the $25 million-$35 million gross profit headwind from Stelara in 2026, specifically if it would be evenly distributed or if Q1 would still be a tougher comp due to prior year forward buying. He also inquired about AI applications beyond claims processing, such as in call centers, workforce optimization, inventory management, and clinician support.

Answer

EVP and CFO Meenal Sethna clarified that the $25 million-$35 million Stelara headwind for 2026 is expected to be evenly distributed, but Q1 will still have a tougher year-over-year comp due to favorable conditions in Q1 2025. President and CEO John Rademacher detailed AI applications in agentic aspects for call centers, workforce optimization, and inventory management, noting these tools augment the team's efficiency and quality. He stated that AI is not yet used in clinical protocols but may support clinicians in areas like note capture.

Albert Rice from Bank of America inquired about the expected progression of EBITDA throughout 2025, given the various moving parts like supplemental payment timing, startup losses, and easier year-over-year comparisons later in the year. He also asked for specifics on rate updates from Medicaid, Medicare, and commercial payers.

Answer

Heather Dixon, an executive, detailed the EBITDA phasing, noting Q1 had the highest startup costs. She identified the timing of the Tennessee DPP as the largest variable and confirmed the full-year outlook for supplemental payments remains positive despite a Q1 decline. Executive Christopher Hunter added that the company's conservative rate outlook is due to general policy uncertainty, not specific negative trends, and that underlying rate growth remains stable.

Albert Rice asked about the drivers behind the moderated revenue per day growth in Q4 and the low single-digit pricing growth guidance for 2025, probing whether it signaled rate pressure or conservatism. He also inquired about the underlying margin assumption for the core portfolio in 2025, excluding specific headwinds.

Answer

CFO Heather Dixon attributed the conservative 2025 rate guidance to a smaller anticipated tailwind from supplemental payments and a prudent approach amid policy uncertainty, while noting commercial rates are assumed stable. For margins, she explained Q4 compression was due to a professional liability reserve and a facility closure. For 2025, she stated that while start-up costs and other headwinds are factored in, the underlying margin of the core business is considered stable and consistent with historical performance.

Albert Rice asked for details on the October volume deceleration, questioning if it was a sudden drop that stabilized or a continuing decline, and whether it was concentrated in specific markets. He also inquired about the impact on joint venture discussions and clinician recruitment.

Answer

CFO Heather Dixon confirmed the volume decline was a step-down at the start of October that then stabilized, rather than deteriorating further. CEO Christopher Hunter added that the joint venture pipeline remains robust and that there has been no material impact on talent recruitment, citing ongoing investments in technology and employee engagement.

A.J. Rice from UBS requested an update on the Latin America acquisition, particularly in Brazil, and the broader M&A pipeline. He also asked about the rationale for moving a cost-generating IT product out of the IKC segment and whether the IKC business is still on track for breakeven. Lastly, he asked for clarification on G&A drivers.

Answer

CEO Javier Rodriguez stated the Brazil acquisition is nearing completion, pending some required divestitures, and that the M&A pipeline remains focused on international opportunities and smaller domestic deals. CFO Joel Ackerman explained the IT product was moved to another segment because its utility expanded beyond IKC to the broader DaVita enterprise, and this does not materially impact IKC's path to profitability. He attributed the G&A per treatment change primarily to lower treatment volume in Q1.

Albert Rice of UBS asked for the underlying growth rate of patient treatment costs, excluding the new impact from oral phosphate binders. He also inquired about capital deployment plans, including share repurchases and the M&A pipeline.

Answer

CFO Joel Ackerman detailed that of the 6.5% midpoint growth in patient care costs, 3.75% is from historical cost inflation for labor and other expenses, which is the comparable figure to prior years. He reiterated the capital allocation strategy of targeting 3-3.5x leverage and returning excess capital via buybacks, noting that while M&A could involve 'hundreds of millions,' it would not significantly alter the repurchase program.

Albert Rice sought clarification on whether the $10-20 million hurricane impact was on EBITDA or revenue, and asked about trends in new patient starts, drivers of mistreatment rates, and the rationale for extending the elevated mortality outlook into 2025.

Answer

CFO Joel Ackerman confirmed the Q4 hurricane impact would be felt almost entirely on EBITDA. He stated that new patient admissions are consistent with prior commentary and that storms added about 10 basis points to the mistreatment rate. Regarding mortality, Ackerman noted that while no new negative trends emerged in the quarter, the persistence of elevated rates informs their cautious outlook for 2025.

A.J. Rice from UBS asked for a reminder of the company's annual M&A capacity, its ultimate leverage target, and how recent acquisitions will affect same-store metrics as they enter the comp base.

Answer

CFO David Doherty reiterated the annual M&A target of around $200 million, which is supportable by internal cash flow while deleveraging towards a sub-3x target leverage ratio. He explained that acquisitions enter the same-store calculation after a full year, and since last year's deals were weighted towards higher-acuity orthopedics, they should provide a positive lift to the rate metric when they are included starting in Q3 2025.

A.J. Rice asked for a potential timeframe on the special committee's review of the Bain Capital proposal and inquired about the 2025 guidance buildup, specifically the expected balance between revenue per case and case growth.

Answer

CEO J. Evans stated he could not comment on the timing of the special committee's process. Regarding 2025 guidance, Evans emphasized looking at the full year rather than quarterly metrics. CFO David Doherty added that for the full year, they expect a relatively balanced contribution from case and rate growth, though mathematical effects from prior acquisitions might continue to mute rate growth in the first half of 2025 before balancing out.

A.J. Rice from UBS inquired how the shift to higher-acuity procedures like total joints affects the balance between volume and pricing metrics over the long term. He also asked if the company experienced any supply chain issues, such as the IV bag shortage.

Answer

Executive Chairman Wayne DeVeydt explained that while higher-acuity cases take more OR time, they have a higher dollar contribution, and the company's long-term growth algorithm of 2-3% for both volume and rate remains the standard, despite quarterly fluctuations. CFO David Doherty confirmed they were aware of the IV bag shortage but, thanks to their procurement team and diverse supply partners, they did not have to cancel any cases and do not anticipate long-term pressure.

A.J. Rice sought clarification on whether labor disruption revenue was influencing the reported stabilization in Nurse and Allied bill rates. He also asked about the impact of weakening demand for Spanish translation services and the reasons for bill-pay spread pressure in the locum tenens business.

Answer

CFO and COO Brian Scott clarified that the travel nurse bill rate stabilization metrics explicitly exclude the more variable rates from labor disruption events. President and CEO Cary Grace noted that while Spanish remains the top language, there has been a modest downturn in its share of the total mix, though overall client demand remains strong. Scott attributed the locum tenens spread pressure to competition and a mix shift toward lower-margin CRNA business, but mentioned that spreads are now stabilizing and momentum is building in higher-margin specialties.

Albert Rice from UBS asked about the normalization of demand patterns versus pre-pandemic levels, the revenue trajectory for 2025, the financial impact of the international business headwind, and the reasons for reduced spending from large clients.

Answer

CEO Caroline Grace noted a return to more normal pre-COVID seasonality in demand. CFO and COO Brian Scott detailed the Q1 outlook, highlighting growth in locums and language services offsetting some headwinds. Grace quantified the international revenue headwind at approximately $100 million over 2024-2025, with the remainder impacting H1 2025. She clarified that large clients reducing spend are rebalancing their permanent-to-contingent staff mix, not changing vendors.

Albert Rice asked about the competitive economics of MSP contracts, margin pressures in the Locums business from specialty mix, and the normalized Q4 EBITDA run rate for 2025.

Answer

President and CEO Cary Grace confirmed the competitive landscape is intense across all service models, not just MSPs. For Locums, she cited bill-pay spread pressure as the primary margin factor. She noted 2025 growth drivers include potential labor disruption revenue and seasonal growth in PLS and language services. Executive Randle Reece clarified the normalized Q4 run rate, suggesting a midpoint revenue of $650 million and an adjusted EBITDA margin of about 8.3%.

Albert Rice of UBS asked about the key drivers behind the strong hospice Average Daily Census (ADC) growth and the factors contributing to the reduction in home health visits per episode.

Answer

CEO Barbara Jacobsmeyer attributed the robust hospice growth to both a 3% rise in referrals and a significant 310 basis point improvement in the admission conversion rate, thanks to new regional admission departments. Regarding home health efficiency, she highlighted the critical role of the fully deployed MetaLogics Pulse tool in optimizing care plans and visit allocation based on patient acuity.

Albert Rice asked for details on the planned 8-10 branch closures, including potential revenue impact and volume consolidation, and also inquired about the 2025 outlook for cost-per-visit metrics.

Answer

CEO Barbara Jacobsmeyer stated that specific financial details regarding the branch closures and consolidations would be provided on the Q4 earnings call. CFO Crissy Carlisle addressed the cost outlook, anticipating a ~3% wage increase in 2025 to remain competitive, which she expects to be partially offset by operating leverage from volume growth and continued productivity improvements.

Asked about the potential impact of various government-related factors, including possible changes to the MSSP program under a new administration, Medicaid changes, and the failure of certain legislation to pass.

Answer

The executive stated they have not heard of any new potential changes to the MSSP program and expect it to remain stable. Any impacts from Medicaid changes are already factored into their guidance, and the unpassed legislation is not expected to have a material effect on the company.

A.J. Rice of UBS asked about the key variables that could cause results to move within the 16-22% EBITDA growth guidance range for 2025, and inquired about any potential opportunities or challenges arising from Washington.

Answer

CEO Parth Mehrotra highlighted the narrowness of the guidance range, underscoring the model's predictability. He identified the primary variable as the performance of the value-based book versus accruals. On the political front, he sees no specific threats, noting strong bipartisan support for the community-based care models and CMS programs Privia participates in.

Albert 'A.J.' Rice of UBS asked for an early outlook on 2025, seeking to understand the primary headwinds and tailwinds the company anticipates.

Answer

CEO Parth Mehrotra declined to give specific 2025 guidance but highlighted the business's predictability, noting 90-95% of metrics are known by year-end. He identified the value-based care book as the biggest variable, which is mitigated by diversification across over 100 programs. Mehrotra reiterated the long-term target of 20% EBITDA growth and expressed confidence for 2025, citing a strong platform and nearly $500 million in cash.

Albert 'A.J.' Rice questioned the updated 2025 guidance, asking if the underlying assumption of flat volumes and pricing was now too conservative following strong Q1 results. He also sought clarity on the sources of management's cited economic uncertainty.

Answer

Executive Mark Ordan explained that the guidance remains conservative due to broad uncertainty in healthcare and the economy, not specific legislative or demographic concerns. He stated the full-year range was raised simply to reflect the significant outperformance already achieved in the first quarter.

Albert Rice inquired about the underlying assumptions for same-facility volume and pricing within the 2025 guidance, and also asked about trends in hospital subsidy negotiations for NICU management.

Answer

CFO Kasandra Rossi explained that the 2025 outlook assumes flat volume and flat pricing, as the significant payer mix tailwind from 2024 is expected to level off. CEO Mark Ordan added that while discussions with hospital partners are continuous, the forecast does not bake in any increase in subsidies or contract economics.

A.J. Rice of UBS asked for clarity on the company's normalized cash flow run rate following the RCM and portfolio changes. He also inquired about the broader capital deployment strategy beyond Q1 2025 and sought clarification on whether the $30 million EBITDA improvement from restructuring is a firm number or includes potential for further efficiencies.

Answer

Executive Charles Lynch provided a historical baseline, suggesting a 60% to 66% conversion of EBITDA to operating cash flow is a good forward-looking guardrail. CFO Kasandra Rossi stated that for 2025, the company will have 'optimal flexibility' to deploy excess cash across M&A, share repurchases, or debt paydown. She clarified the $30 million EBITDA improvement is an estimate with potential upside, as it is intended to cover all costs of exiting practices, and the company will continue to seek further efficiencies.

A.J. Rice inquired about the impact of the current economic environment on the 2026 selling season for both PBM and commercial health plans, and whether economic uncertainty specifically drives growth in the under-500 'Select' segment.

Answer

President and COO Brian Evanko characterized the selling season as active, with PBM retention tracking toward the mid-90s. He noted affordability and personalized solutions are key client themes. He attributed the strong 9% customer growth in the Select segment to Cigna's funding-agnostic approach and improved affordability, rather than a direct correlation with economic uncertainty.

A.J. Rice from UBS sought clarification on the 2025 guidance, asking about the net earnings impact from the Medicare business divestiture and subsequent capital redeployment. He also asked if Evernorth's margins would see a favorable step-up in 2025 as large contracts mature.

Answer

CFO Brian Evanko confirmed the 2025 outlook reflects the Medicare sale, with the majority of proceeds earmarked for share repurchase. He provided a normalized 2024 Cigna Healthcare earnings base of slightly below $4 billion to aid comparison. He also stated that the maturation of large client contracts is already factored into Evernorth's 2025 guidance, which aligns with the long-term growth targets on a normalized basis.

Albert Rice asked about The Cigna Group's 2025 commercial cost trend outlook and potential employer pushback, and also questioned Evernorth's primary care strategy following the VillageMD investment write-down.

Answer

CFO Brian Evanko stated that Cigna expects cost trends to remain elevated in 2025 and is pricing for rate increases greater than 2024. CEO David Cordani addressed the VillageMD situation, calling the timing of the investment poor due to market disruption. He noted that while Evernorth's accountable care relationships will continue, the company will take a 'paced path' given the current environment and focus on capabilities like CuraScript.

A.J. Rice asked about the progress of the infusion business repositioning and whether it's on pace for its long-term growth goals, including any tailwind from CVS's exit. He also asked if the Amedisys deal is additive to the typical M&A capital deployment.

Answer

CEO Jon Rousseau stated that the impact from Quorum's market exit is largely baked in at this point. He expressed positive thoughts on the overall infusion market and confirmed the business is on track to hit its internal budget for the year. Regarding M&A, he reiterated that the potential deal is a unique situation that fits their philosophy but is separate from their typical tuck-in M&A mode, and he looks forward to sharing more details later.

Albert 'A.J.' Rice asked about the drivers behind BrightSpring's success in securing exclusive or narrow contracts for limited distribution drugs (LDDs) and questioned if the competitive landscape has changed. He also inquired about the growth trajectory and margin potential of the Infusion business following recent investments.

Answer

Executive Jon Rousseau attributed the LDD success to a long-standing focus on operational excellence and high service levels, resulting in top-tier Net Promoter Scores, rather than a material shift in the market. He noted a trend toward narrower networks for niche therapies, where BrightSpring is a chosen partner. For the Infusion business, Rousseau highlighted that a new team and process standardization have led to best-in-class turnaround times, positioning the segment for a return to growth, with a target of over 20% for the year.

Albert Rice of UBS requested an update on the onboarding of a large long-term care operator and discussions with a managed care plan for home health. He also asked about the expected financial contribution from the recently closed Haven Hospice acquisition.

Answer

CEO Jon Rousseau confirmed the successful onboarding of a major customer across over 200 facilities, which is expected to contribute approximately $1 million in monthly EBITDA once start-up costs normalize. He noted that discussions with payers for home-based primary care are progressing well. Regarding the Haven acquisition, Rousseau projected it would contribute $1-2 million in EBITDA in the current year, with the potential to become a $15 million opportunity over several years.

A.J. Rice questioned the transition of preneed funeral sales to an insurance model, the potential revenue uplift from merchandise in the backlog, and the capital deployment strategy between M&A and share repurchases.

Answer

CEO Thomas Ryan explained that the transition to an insurance model, particularly for SCI Direct, is temporarily slowing sales but will ultimately increase general agency revenue and significantly boost the average revenue per service as contracts mature. CFO Eric Tanzberger stated that capital deployment is opportunistic, with share repurchases being attractive in Q1. He affirmed the M&A pipeline is strong and the company expects to meet its annual acquisition spending target.

Albert 'A.J.' Rice from UBS asked about the recent volatility in funeral volumes and the revised 2025 outlook, the specifics of the transition from trust to preneed insurance sales, and the strength of the M&A pipeline after a strong year of acquisitions.

Answer

Chairman and CEO Tom Ryan attributed volume volatility to the diminishing ripple effects of COVID and a normalization of mortality trends, leading to a 'flat to slightly down' volume outlook for 2025. He clarified the preneed insurance transition is occurring differently in the SCI Direct and core channels, aiming for more stable, underwritten products. Executive Eric Tanzberger described the M&A pipeline as robust and expressed optimism for exceeding the $75-$125 million guidance, similar to the prior year, contingent on deal timing.

Albert Rice asked for the rationale behind anticipating more positive funeral volume trends, the company's updated thinking on the COVID pull-forward effect, whether the strong acquisition pace contributes to confidence in growth targets, and for perspective on recent management changes.

Answer

Chairman and CEO Thomas Ryan explained that the primary driver for the volume outlook is the diminishing pull-forward effect from the pandemic, combined with population growth and a strong preneed backlog. He noted that the recent strong acquisitions will contribute to growth targets, as they are high-quality, tuck-in businesses in major markets offering synergy potential. Regarding management changes, Ryan stated they were part of a long-term succession plan triggered by an executive's approaching retirement, and the company is excited about the elevated responsibilities for the named executives.

A.J. Rice inquired about the deal pipeline, asking if the competitive landscape for acquisitions is easing and about the potential economics in newer markets like the Southeast. He also asked if the policy discussions in Washington are impacting state-level Medicaid rate negotiations and what the company anticipates for composite Medicaid rate updates.

Answer

Chief Investment Officer Chad Keetch responded that competition for deals remains consistent, but Ensign often wins due to its operational reputation and closing track record. He expressed confidence in achieving strong economics in new markets by relying on local leaders' expertise. CEO Barry Port addressed the state-level question, stating that states are not proactively planning for federal policy changes due to the uncertainty in Washington. He noted Ensign has good visibility on rates for the current year. CFO Suzanne Snapper added that the company is in continuous discussion with states about rate setting, educating them on local market conditions.

A.J. Rice inquired about labor cost trends for 2025, the impact of California's Workforce Standards program, the current deal pipeline, and the competitive landscape for acquisitions.

Answer

COO Spencer Burton noted a gradual improvement in the labor market and highlighted the company's relentless focus on attracting and retaining talent through local leadership development. CFO Suzanne Snapper confirmed that the costs associated with the California Workforce Standards program are fully baked into the 2025 guidance. Regarding M&A, Executive Chad Keetch described the deal flow as very strong, with more opportunities than they can pursue, allowing them to be highly selective. He reiterated their disciplined approach, focusing on having local leaders in place and adhering to strict valuation criteria, such as using trailing-12-month performance for rent calculations and maintaining a focus on price per bed.

A.J. Rice sought high-level commentary on the trajectory toward the 3% MA pretax margin target, given the mix of factors like the Stars litigation, Part D changes, and the favorable rate update.

Answer

CEO Jim Rechtin responded that, excluding the unknown Stars outcome, the company feels good about the underlying progress of the business. He acknowledged the various external puts and takes but stressed that management's focus is on controllable elements like medical costs, G&A, and Stars performance, with more detail to come at the June investor conference.

Albert Rice sought more clarity on the Stars commentary, questioning the cautious tone for the 2027 payment year compared to the more confident outlook for 2028, and asked if the 2026 appeal outcome would affect 2027.

Answer

CEO James Rechtin clarified that the 2026 litigation is separate from 2027 performance. He reiterated that while operational progress in Q4 2024 was strong, uncertainty around 2027 thresholds remains, consistent with prior commentary. For 2028, he expressed more confidence due to having a full year of runway to implement changes. George Renaudin, President of the Insurance Segment, added that new Q4 initiatives were successful, but the cautious tone reflects prudent planning.

A.J. Rice asked if a successful Stars appeal would lessen the need for investment in 2025 and questioned the company's philosophy on the trade-off between enrollment and margin in its effort to reach a 3% margin by 2027.

Answer

CEO Jim Rechtin clarified that the investment need is driven by the broad trend of rising Stars thresholds, separate from the specific appeal. On the strategic trade-off, he stated it's too early to provide a definitive answer but the company's intent is to balance long-term earnings potential with near-term progression, without harming the business long-term.

Asked if states are lowering base Medicaid rates due to the existence of supplemental programs and inquired about the potential impact of a reduction in the federal provider tax cap from 6% to 5%.

Answer

The company has not seen states materially lowering base Medicaid rates. While they have analyzed the potential impact of a lower provider tax cap, they are not providing an estimate due to the complexity. They noted that key states like Texas and Florida are currently under the 6% cap, which would limit the impact there.

Albert (A.J.) Rice of UBS asked for the key assumptions behind the previously estimated $50 million headwind from a potential expiration of ACA exchange subsidies. He also inquired about the financial impact of new hospital openings in Las Vegas and D.C. on the 2025 guidance and same-store metrics.

Answer

Executive Steve Filton reiterated that the ACA subsidy impact is a high-level estimate, assuming about half of the company's exchange-covered patients would lose coverage. Regarding new hospitals, he stated they are expected to be EBITDA-positive combined in 2025 and, while they will likely depress same-store volume metrics via cannibalization, they should not be a drag on consolidated earnings.

A.J. Rice from UBS asked for broader comments on labor trends and capital deployment priorities, including the behavioral JV pipeline, M&A, and share buybacks.

Answer

Steve Filton stated that labor trends have stabilized, with wage inflation lower and premium pay usage diminishing. For capital deployment, he indicated a continued focus on capital expenditures, including restarting bed additions in the behavioral business, and share repurchases. He noted that while M&A opportunities are reviewed, few have been compelling recently.

A.J. Rice questioned the key drivers of the 2.9% growth in revenue per adjusted admission and asked if the political discussions in Washington are impacting managed care contract negotiations.

Answer

CFO Mike Marks explained that the revenue growth was driven by a favorable payer mix and higher acuity in outpatient services. He noted that contracting is well-advanced for 2025, 2026, and 2027 at rates consistent with targets. CEO Sam Hazen added that HCA has improved its overall managed care positioning, citing new, broad participation agreements with Kaiser in Denver and an advanced position with a Blue Cross product in Chattanooga.

A.J. Rice inquired about the strong managed care admissions, asking about the status of 2025-2026 pricing contracts and any changes in utilization review or denial rates from MCOs.

Answer

CFO Mike Marks stated that HCA is 80% contracted for 2025 and 60% for 2026, with pricing on target. He noted that while there is a lot of activity around denials and underpayments, HCA's enhanced capabilities have prevented it from becoming a material impact for the company in 2024.

Albert J. Rice from UBS asked for clarification on the 2025 earnings outlook framework, particularly how to model the impact of hurricanes and their recovery, and questioned which service lines were driving continued volume strength.

Answer

CFO Mike Marks clarified that the preliminary 2025 outlook, which anticipates growth near or slightly above the high end of their long-term range, already accounts for manageable, lingering hurricane effects. CEO Sam Hazen added that volume strength is broad-based, with emergency room and cardiac services being particularly strong performers.

Albert Rice inquired about Washington-related policy, asking if the previously estimated $1 per share headwind from the potential expiration of enhanced APTCs is still accurate. He also asked for a conceptual framework on the potential business impact and operational burden of Medicaid work requirements.

Answer

CEO Sarah London stated that the $1 per share headwind estimate for APTC expiration remains valid, with further analysis pending on the interplay with new Marketplace rules. Regarding work requirements, she noted Centene's past experience, explaining that the impact would vary by state and that the company sees an opportunity to work with state partners on implementation to ensure member access to care.

A.J. Rice asked about underlying utilization trends in Medicaid and the drivers of the better-than-expected Medicare medical loss ratio, specifically distinguishing between cost trends and reserve adjustments.

Answer

CEO Sarah London confirmed that underlying Medicaid trends remain stable with no new developments to report. CFO Andrew Asher clarified that the outperformance in the Medicare segment was largely driven by a very strong performance in the Part D (PDP) business, which provides confidence heading into 2025 amid further IRA changes.

AJ Rice sought to compare Centene's 4.5% to 5% composite rate update with peers who have cited needs for higher increases, asking what rate level Centene requires to achieve its MLR improvement goals.

Answer

CEO Sarah London responded that rate needs are state-specific and that work on sufficiency continues. CFO Andrew Asher added that Centene has secured high-single-digit rate increases in smaller states, demonstrating that states are responsive to data. He emphasized that the company continues to work on future rate cycles.

A.J. Rice from UBS inquired about the 14% increase in benefit expense as a headwind and what could be done to manage it, and also requested an update on the status of Palmetto audits and the TPE program.

Answer

CFO Douglas Coltharp explained that benefit expense is about 10-11% of total SWB and that while they proactively manage plan design, they expect the growth rate to moderate in the second half of the year as they anniversary the increase. On audits, he noted that TPE activity from Palmetto was low in Q1 but can be 'lumpy,' and the company has factored this potential into its full-year bad debt assumption, while also noting a high success rate on claims that are reviewed.

A.J. Rice questioned the competitive landscape in Florida, asking if the market was at risk of becoming over-saturated with IRF beds. He also inquired about potential regulatory focus from the new administration and the company's advocacy efforts on prior authorization.

Answer

CEO Mark Tarr asserted that Florida is not overbedded due to strong demographics and that Encompass Health's first-mover strategy secured a leading position. CFO Douglas Coltharp added that the market had a significant supply deficit before the CON law change. On the regulatory front, Tarr sees no specific near-term threats, while Coltharp noted their advocacy focuses on improving MA pre-authorization and network adequacy rules.

A.J. Rice inquired about the status of Directed Payment Programs (DPP) in Tennessee and New Mexico and asked for updates on potential new programs in Alabama, Arkansas, and Indiana. He also asked about the volume and growth from public health insurance exchanges.

Answer

CFO Kevin Hammons reported that while there was no specific news on the Tennessee or New Mexico DPPs, recent approvals in other states are a positive sign. He noted that a program in Indiana looks positive, while Alabama is in early discussions. Hammons also stated that revenue from public exchanges is less than 6% of total net revenue. CEO Tim Hingtgen added that the company is actively advocating for the extension of enhanced premium tax credits for the exchanges.

A.J. Rice requested details on the assumptions behind the $75 million to $100 million organic growth forecast, specifically same-store metrics. He also asked why CHS did not book the Tennessee DPP for the 2024 stub period and sought an update on the progress of potential new DPPs in Alabama, Indiana, and Arkansas.

Answer

Kevin Hammons, President and CFO, outlined the organic growth assumptions, including 2-3% volume growth, similar pricing, and an 8-12% increase in medical specialist fees, offset by $40-60 million in ERP savings. He explained that the Tennessee DPP was not booked because its funding mechanism had not yet been approved by CMS. Regarding new states, he noted Indiana is the furthest along in legislative consideration, while discussions in Alabama and Arkansas are in earlier stages and unlikely to impact 2025.

A.J. Rice of UBS sought a detailed breakdown of the $40 million EBITDA guidance reduction, questioning the allocation between Q3 performance and Q4 expectations, and asked about the root cause of the increased claim denials, particularly within Medicare Advantage.

Answer

President and CFO Kevin Hammons explained that roughly half the guidance cut stemmed from the Q3 miss, with the remainder attributed to Q4 impacts from hurricane-related hospital closures and continued claim denial pressure. He clarified that the increased denials, while prominent in Medicare Advantage, are becoming more broad-based and aggressive across various areas and are not solely tied to the 2-midnight rule.

Albert Rice questioned whether the political discussions in Washington regarding potential Medicaid cuts are affecting state-level conversations about rate updates or RFP processes.

Answer

CEO Joseph Zubretsky stated definitively that the Washington political backdrop is not impacting state-level discussions. He explained that rate negotiations are purely actuarial, focusing on specific cost trends, and the RFP cycle is currently at a low point and proceeding without influence from federal budget debates.

A.J. Rice from UBS inquired about the expected quarterly earnings progression for 2025, considering factors like start-up costs and seasonality. He also asked for Molina's perspective on how states might respond to potential federal Medicaid funding changes and the resulting impact on the business.

Answer

CFO Mark Keim projected a very evenly distributed 50-50 earnings split between the first and second halves of 2025, a departure from the typical front-loaded year. This is due to front-loaded G&A for new contract implementations offsetting other seasonal factors. On the political landscape, CEO Joe Zubretsky argued that any major federal funding cuts are unlikely to result in significant program changes, as the necessary actions—cutting enrollment, benefits, or provider payments—are politically untenable for both parties at the state level.

A.J. Rice from UBS questioned why Molina's expected Medicaid rate needs (around 6%) differ from peers suggesting double-digit increases and whether states can afford such updates. He also asked if rising utilization trends are a market-wide issue or if there are specific medical management opportunities for Molina.

Answer

President and CEO Joe Zubretsky expressed confidence, citing significant on-cycle and off-cycle rate increases in the second half of 2024, with Q4 on-cycle rates averaging 9%. He stated the model of using risk corridors as a buffer while rates catch up to trend is working as expected. Zubretsky also affirmed Molina's proven ability to manage medical costs effectively, noting the company's history of operating deep within risk corridors, which provides a financial buffer regardless of gross trend.

Albert Rice (A. J. Rice) inquired whether the court ruling on minimum staffing rules was merely removing an overhang or actively changing behavior, questioned the sustainability of strong Q1 margins, and asked for an update on food and labor inflation trends.

Answer

Theodore Wahl (executive) clarified that the court ruling primarily removed a future overhang rather than changing current operator behavior. He attributed strong Q1 margins to solid service execution and strategic investments in SG&A that improve compliance and customer experience. Matthew McKee (executive) added that while food inflation saw a sequential increase, the overall labor market for healthcare is showing strong recovery, with HCSG's wage growth remaining stable and job applications high.

Albert Rice questioned the drivers of the Q1 revenue guidance, asking about the contribution from new business versus Q4 carry-over and any potential seasonality in contract wins. He also asked about the embedded assumptions for labor and food inflation in the 2025 outlook.

Answer

Executive Theodore Wahl stated that there is no significant seasonal pattern to new business wins. He attributed the Q1 revenue outlook to momentum from new business added throughout Q4, a client retention rate greater than 90%, and a strong pipeline. Executive Matthew McKee detailed that while food inflation is ticking up, wage inflation has moderated. He stressed that HCSG's modified contracts provide the right to pass through inflation for food, supplies, and wages, ensuring the durability of the business model.

A.J. Rice inquired about the hourly labor market, asking if wage increases were adequate to staff client facilities. He also asked for an update on food inflation trends and the company's capital deployment strategy, particularly regarding share buybacks and inorganic growth.

Answer

Executive Matthew McKee described the labor market as stabilizing, with the industry workforce on track to recover to pre-pandemic levels by late 2026, though challenges persist in rural markets. He noted food inflation was 40 basis points for the quarter. Executive Theodore Wahl explained that capital allocation is holistic, with share repurchases viewed as opportunistic. He also confirmed the company is always evaluating complementary inorganic growth opportunities and sees potential for more activity in the year ahead.

Albert Rice inquired about several aspects of Elevance Health's Medicare Advantage business, including trends in group MA, the observed impact of IRA changes, and the company's confidence in its visibility on elevated cost trends for the remainder of the year.

Answer

Mark Kaye, CFO, stated that overall Medicare costs remain elevated but manageable and consistent with Q4 and initial Q1 expectations. He noted that while flu and respiratory illnesses caused a slight uptick in utilization, these costs moderated by the end of the quarter. Mr. Kaye affirmed the company's comfort with the current trend environment based on recent data. Gail Boudreaux, President and CEO, reiterated that performance is aligned with their expectations.

Albert Rice of UBS inquired about Elevance Health's 2025 Medicare Advantage (MA) enrollment guidance of 7-9%, asking if the annual enrollment period (AEP) results were fully reflected and what member demographics were attracted. He also sought confirmation on the 2025 MA margin outlook.

Answer

CEO Gail Boudreaux expressed confidence in the MA enrollment guidance, highlighting strong member retention. Felicia Norwood, President of Government Health Benefits, confirmed that AEP performance aligned with expectations, driven by retention and stable offerings, with notable strength in HMO growth. CFO Mark Kaye added that the company is well-positioned to achieve margin stability in its MA business for 2025.

Albert Rice of UBS questioned how Elevance Health reconciles its long-term 12% EPS growth target with the revised 2024 outlook and a projected 5% growth for 2025, asking if correcting Medicaid rates alone would be sufficient to accelerate growth back to the target.

Answer

CEO Gail Boudreaux reaffirmed confidence in the long-term 12% adjusted EPS growth target, citing strong revenue momentum in the Commercial and Carelon segments. She acknowledged that Medicaid margins will remain below their long-term target in 2025 due to a "time-bound" mismatch between rates and member acuity, but stressed the company is investing for the long term and will navigate the current dynamics with discipline.

A.J. Rice sought clarification on Medicare Advantage trends, asking if elevated care was primarily on the group side, if competitive exits only impacted Optum, and how the Part D business was performing since it was not mentioned.

Answer

Timothy Noel, an executive, responded, confirming the care activity pressure was concentrated in the community and group MA books, with a slightly more pronounced effect in the group business. He clarified that pressures from last year, like provider upcoding and specialty drugs, were tracking as planned, and the issues from competitive exits were primarily an Optum-side factor.

Albert Rice of UBS asked about the drivers of the fourth-quarter medical loss ratio (MLR) variance, whether the intensity of cost trends changed, and if Q4 results impacted confidence in the 2025 MLR outlook.

Answer

CEO Andrew Witty affirmed that nothing seen in Q4 changed their positive view for 2025, citing a better membership mix. Executive John Rex elaborated that Q4 MLR was impacted by normal seasonality, non-run rate revenue effects like group MA refunds (80-90 bps), and seasonal flu/RSV (50-60 bps). He noted that trends in hospital coding intensity and specialty drug prescribing had stabilized at previously elevated levels and were incorporated into the 2025 outlook.

Albert Rice of UBS asked about the drivers of the fourth-quarter medical loss ratio (MLR) variance, whether cost trend intensity changed, and if Q4 results impacted confidence in the 2025 MLR outlook.

Answer

Executive Andrew Witty confirmed that nothing seen in Q4 changed the company's positive view for 2025. Executive John Rex elaborated that Q4 MLR drivers were consistent with Q3 trends but included a notable 80-90 basis point impact from non-run rate revenue effects, such as group MA refunds, and a 50-60 basis point seasonal impact from flu and RSV.

A.J. Rice asked for a breakdown of the headwinds and tailwinds that are shaping the preliminary 2025 outlook of around 8% growth, which is below the company's long-term 13% to 16% target.

Answer

Andrew Witty, CEO, explained that the conservative 2025 outlook balances significant external pressures, like government funding reductions and lingering COVID effects, with the need to continue investing in long-term growth drivers. He emphasized that the company will not pull back on crucial investments in value-based care platforms and technology modernization, ensuring the plan is responsible for long-term value creation despite the near-term headwinds.

A.J. Rice inquired if the 20% order pickup is due to seasonality or a new underlying trend, asked about the strategic capital deployment plans, and requested details on the size and economics of the home healthcare staffing business.

Answer

CEO John Martins and Group President Marc Krug confirmed the order growth is broad-based across most specialties, not just seasonal. Regarding capital, Martins stated the focus is a combination of M&A readiness, opportunistic share buybacks, and internal technology investments. CFO William Burns sized the home care staffing business at a run-rate approaching $110-120 million with gross margins above the consolidated company average.

A.J. Rice asked if the 20% order pickup was driven by seasonal factors or an underlying trend, sought clarity on the capital allocation strategy shifting from buybacks to strategic investments, and requested details on the home healthcare staffing business.

Answer

CEO John Martins explained the demand increase is partly seasonal but also broad-based, a point echoed by Marc Krug, Group President of Delivery, who noted growth across nearly all specialties. Martins confirmed the capital allocation strategy involves preparing for M&A, investing in technology, and remaining opportunistic on buybacks. CFO William Burns sized the home care staffing business at a run-rate approaching $110-$120 million with gross margins above the consolidated average.

A.J. Rice of UBS sought clarification on the variance between guided and actual results for bill rates and FTEs, asking if business mix was the primary driver. He also inquired about the competitive landscape and whether the anticipated shakeout of smaller firms is materializing.

Answer

CFO William Burns attributed variances to business mix, noting that stronger growth in lower-bill-rate segments like Homecare impacted the overall average, but that travel bill rates specifically tracked to expectations. On the competitive landscape, CEO John Martins stated that the market remains 'tremendously competitive' and the shakeout of smaller firms is 'still in process.' He believes smaller companies lacking proprietary MSP or VMS contracts will continue to be challenged by the constrained margin environment.

A.J. Rice questioned the variance between the actual sequential rate decline and prior guidance, and asked for an update on the competitive landscape and the potential for a shakeout among smaller firms.

Answer

CFO William Burns clarified that the rate variance was primarily due to business mix, with stronger growth in lower-bill-rate segments, rather than a larger-than-expected drop in travel nurse rates. CEO John Martins described the market as 'tremendously competitive' and believes smaller firms without direct client contracts will be challenged by margin pressures, though he noted this shakeout is still 'in process.'

A.J. Rice from UBS questioned the Q1 gross margin miss relative to guidance, asking about pressures on the bill-pay spread and whether competitive intensity is easing. He also sought an update on nurse supply and whether traveler rate expectations have reset.

Answer

CFO Bill Burns explained the gross margin miss was due to higher-than-expected burden charges, including health insurance, workers' comp, and a non-recurring professional liability adjustment. CEO John Martins and Group President Marc Krug confirmed that nurse rate expectations have largely reset, as many travelers who were 'chasing dollars' have returned to permanent roles, leaving a more traditional traveler base.

A.J. Rice asked for clarification on USPI's 1% same-facility volume growth, its connection to the high-acuity strategy, and the path to higher growth. He also inquired about capital deployment, asking if Tenet would accelerate USPI M&A, share buybacks, or consider a dividend.

Answer

Chairman and CEO Dr. Saum Sutaria explained that the USPI volume pattern was anticipated due to difficult 2023 comparisons and that the focus on higher acuity continues. Regarding capital, he emphasized that accelerating investment in USPI is the most value-accretive action. He noted that while debt paydown is a priority, the company's strong cash position provides flexibility to be more proactive on both M&A and share repurchases.

Albert Rice from Crédit Suisse asked about the quarterly decline in the LPN utilization ratio and whether the company could still achieve its 50%+ target for the year. He also inquired about referral trends from skilled nursing facilities for both home health and hospice.

Answer

CEO Chris Gerard attributed the LPN utilization dip to Omicron-related quarantines and the mathematical effect of lower overall visits per episode. He reaffirmed confidence in reaching the 50%+ LPN utilization goal for the year. Regarding nursing homes, he explained that their lower-than-normal occupancy currently limits the hospice referral pool but diverts more patients to home health. He views the eventual recovery of SNF occupancy as a net positive opportunity for Amedisys.