Raj Kumar

Raj Kumar of Stephens Inc. asked about the contribution from California's Workforce and Quality Incentive Program, which is set to end, and discussions to maintain funding. He also inquired if Ensign's clusters are engaging with payers in value-based care models to close the reimbursement gap with fee-for-service.

Answer

CFO Suzanne Snapper clarified that funding from the California program is expected through 2026 and that Ensign is in discussions to have those funds rolled back into the base rate. She also confirmed Ensign actively partners with MCOs on value-based care models, creating unique programs for local markets, though the current volume from these programs is relatively small.

Raj Kumar, on for Scott Fidel, asked about expectations for quarterly EPS seasonality in 2025 and the outlook for cash flow from operations, including any unique factors for the upcoming year.

Answer

CFO Suzanne Snapper explained that Q1 and Q4 are historically the strongest quarters for occupancy and skilled mix, and this trend is expected to continue in 2025. She noted that Q4 2024's performance was strong, continuing momentum from an exceptional Q3. For cash flow, Suzanne highlighted that heavy acquisition activity is causing temporary delays in licensing and Medicaid certifications, which can stretch the cash conversion cycle. Executive Chad Keetch confirmed this is a short-term issue. Suzanne also reminded listeners of a previously disclosed settlement payment made in Q4 which impacted cash flow for that period.

Raj Kumar asked about the estimated headwind from satellite consolidations in Q4 and whether negative headlines earlier in Q3 impacted referral patterns. He also inquired about the breakdown of pre-opening and startup costs, specifically how much of the Q4 spend relates to 2026 hospital openings.

Answer

President and CEO Mark Tarr confirmed no impact on referral patterns from negative headlines, citing proactive communication with partners and referral sources. CFO Doug Coltharp estimated the Q4 headwind from satellite closures at 25-30 basis points, down from 35 basis points in Q3, as volume consolidates. He stated that the full-year estimate for pre-opening and startup costs is $18 million-$22 million, with Q4 likely pegging the midpoint. A portion of Q4 spend will relate to early 2026 openings, and 2026 costs are expected to be in a similar range, including some expenses for 2027 openings.

Raj Kumar asked about the embedded year-on-year growth headwind from satellite consolidations in Q4 2025 and whether recent negative headlines had impacted referral patterns. He also inquired about the pre-opening and startup costs, specifically how much of the Q4 spend relates to the three hospitals opening in Q4 and assumptions for 2026 spend given a back-half weighted pipeline.

Answer

President and CEO Mark Tarr confirmed no impact on referral patterns from negative headlines, citing proactive communication with partners and referral sources. CFO Doug Coltharp estimated the Q4 headwind from satellite closures to be slightly less than Q3, around 25 to 30 basis points, as volume consolidates. Regarding pre-opening and startup costs, Doug Coltharp stated the full-year estimate is $18 million to $22 million, with Q4 spend primarily related to Q4 openings and a portion applicable to early 2026 openings. He suggested that a good proxy for 2026 spend would be a similar range to the full-year 2025 estimate.

Raj Kumar of Stephens Inc. inquired about the outlook for same-store growth given tough comparisons and asked about the drivers of the sequential increase in outpatient visits.

Answer

EVP & CFO Doug Coltharp acknowledged the tough comps but noted EHC's volumes don't correlate with acute care trends due to the non-discretionary nature of its patients. EVP & COO Pat Tuer clarified that the outpatient business is small and its performance is based on market-specific strategies, not a national push, with revenue benefiting from supplemental Medicaid payments.

Raj Kumar sought to understand the behavioral health supply-demand dynamics, specifically the high single-digit SWB growth versus slightly negative to positive volumes, and whether staffing increases are for better volume growth or maintaining capacity. In a follow-up, he asked about the step-up in acquisition spend, assuming it's for outpatient behavioral acceleration, and what to expect for future capital deployment on M&A in that area.

Answer

CFO Steve Filton explained that muted behavioral volumes are due to labor scarcity in a quarter to a third of hospitals and increased national outpatient utilization, which is delivered in fragmented settings. He stated that hiring numbers are increasing, and SWB growth is partly preparing for increased patient volume, especially in outpatient. Regarding acquisition spending, Filton clarified that the approximately $35 million-$40 million was mostly in the U.K. on the inpatient side. He noted that U.S. outpatient expansion requires less capital (around $1 million-$2 million per clinic), with the primary challenge being finding appropriate therapists.

Raj Kumar inquired about the behavioral health supply-demand dynamic, specifically how high single-digit SWB growth aligns with modest volume growth, and whether staffing increases are for future volume or maintaining current capacity. He also asked about the recent step-up in acquisition spend and future capital deployment on M&A for outpatient behavioral acceleration.

Answer

CFO Steve Filton attributed muted behavioral volumes to labor scarcity in some hospitals, noting hiring is incrementally increasing. He explained that increased outpatient utilization is fragmented, and UHS is staffing up to capture more of this activity through better focus and new outpatient facilities. He clarified that the acquisition spend was mostly for inpatient facilities in the UK, and US outpatient clinics require minimal capital ($1-2 million per clinic), with the main challenge being therapist availability.

Raj Kumar of Stephens Inc. asked about the potential puts and takes for UHS from the proposed elimination of the inpatient-only list, also known as site neutrality proposals, and its impact on admissions and rate growth.

Answer

Executive VP & CFO Steve Filton responded that it is difficult to project the impact without knowing the specific details of a final bill. He noted that the industry is lobbying hard against further cuts, but the ultimate effect depends on the final legislation, as the 'devil is always in the details' with such proposals.

Raj Kumar inquired about the year-over-year trend in professional fees, the expected trend for Valesco in Q4 and 2026, and opportunities to achieve break-even.

Answer

CFO Mike Marks noted that same-facility professional fees increased 11% year-over-year in Q3, running hotter than average inflation, primarily due to anesthesia and radiology. CEO Sam Hazen added that Valesco is expected to show continued financial improvement into 2026, along with clinical and patient engagement improvements.

Raj Kumar from Stephens Inc asked about the year-over-year trend in professional fees, Valesco's historical drag on EBITDA, and opportunities to achieve break-even in 2026.

Answer

CFO Mike Marks reported a 11% increase in same-facility professional fees year-over-year in Q3, primarily driven by anesthesia and radiology. CEO Sam Hazen added that HCA expects continued financial improvement for Valesco into 2026, noting favorable progression in its financial performance and strategic benefits.

Raj Kumar from Stephens Inc. inquired about the progress on the $600-800 million targeted savings plan from the Investor Day and whether new opportunities have been identified for HCA's financial resiliency initiatives.

Answer

CFO Mike Marks confirmed HCA is actively pursuing its resiliency program, which includes benchmarking, automation, digital transformation, and leveraging shared services. He stated that in light of potential policy challenges, these efforts have been 'both accelerated and enhanced' over the last 12-18 months. A more comprehensive update will be provided on the Q4 2025 earnings call.

Raj Kumar requested details on the recent Managed HealthCARE Pharmacy acquisition, the broader Pacific Northwest expansion strategy, and sought an update on penetration with large regional and national assisted living facility (ALF) accounts.

Answer

CFO David Morris characterized the recent Oregon acquisition as a 'typical deal' within their strategic sweet spot, noting it comes with a strong leadership team to help capitalize on national accounts in the Pacific Northwest. He reiterated that H2 organic growth is expected to align with high single-digit guidance, with the 11 newest locations being key future growth drivers.

Raj Kumar of Stephens inquired about observed drug mix trends during the fourth quarter and what pricing assumptions are embedded in the 2025 guidance. He also requested an update on the progress of pilot initiatives for clinical intervention services, such as fall risk and disease state management.

Answer

Executive David Morris stated that for 2025, no substantial changes are expected regarding drug mix or reimbursement, with trends remaining relatively steady. On the topic of clinical initiatives, Executive Fred Burke expressed pride in the data analytics and clinical teams, confirming they are making great progress on value-added services and that customers are enthusiastic about the developments.

Raj Kumar of Stephens Inc. requested details on the assumptions for senior living occupancy, revenue per room, and margins embedded in the updated guidance. He also asked if the large Amedisys acquisition would pause the company's typical M&A cadence for smaller, turnaround operations.

Answer

CFO Lynette Walbom clarified that the guidance includes a roughly 6% rate increase and 30-50 basis points of occupancy growth for senior living. President & COO John Gochnour and CEO Brent Guerisoli explained that while the primary focus will be on integrating the Amedisys assets, the company's decentralized portfolio model allows other leaders and portfolio companies to continue pursuing their own growth strategies, ensuring the 'flywheel' continues to turn.

Raj Kumar of Stephens Inc. asked for details on the Medical Solutions preferred payer strategy, including its revenue impact and margin outlook. He also inquired about the full-year free cash flow forecast and capital allocation priorities like debt paydown.

Answer

CFO Matt Buckhalter explained the Medical Solutions preferred payer strategy is expanding from 18 contracts and that gross margins, which were 45.6% in Q2, will normalize to the 42-44% range in the second half. He highlighted the strong $37 million in free cash flow year-to-date and expects to generate more. The current priority for cash is maintaining liquidity for future M&A opportunities rather than debt paydown.

Raj Kumar of Stephens Inc. sought Ardent's perspective on the proposed elimination of the inpatient-only list and its potential effect on inpatient volume growth. He also asked for clarification on the timeline for achieving the 100-200 basis points of margin expansion targeted by the IMPACT program.

Answer

President & CEO Marty Bonick stated that the shift from inpatient to outpatient has been steady and is driven by clinical acuity, so eliminating the list isn't expected to cause a sudden flood to outpatient settings. He noted it reinforces their strategy of growing their outpatient and ASC footprint. CFO Alfred Lumsdaine explained that the IMPACT program is an intentional acceleration of their margin goals, aiming to realize the bulk of the 100-200 bps improvement in the next 24 months to proactively mitigate regulatory headwinds that begin in 2028.

Raj Kumar asked for factors beyond Medicaid dynamics, such as labor or competition, that might explain the gap between strong macro demand and modest same-store metrics. He also requested an update on the penetration of PHP/IOP programs.

Answer

CEO Christopher Hunter acknowledged that healthcare is local and that factors like staffing can be headwinds in specific markets, but did not call out any broad competitive issues. He stated that expanding PHP/IOP step-down services remains a key growth opportunity to improve patient outcomes, and the company is focused on enhancing these referral patterns internally.

Raj Kumar of Stephens Inc. asked about a Department of Labor proposal on companionship services and overtime, potential hospice cap issues, and the risk of increased sequestration due to the federal deficit.

Answer

President & COO Bradley Bickham noted the DOL proposal would have minimal impact due to service complexities and existing union contracts, and confirmed a manageable hospice cap accrual of just over $1 million. Chairman & CEO Dirk Allison addressed sequestration, stating that the company expects Congress to waive the automatic increase, consistent with past actions and the administration's stance against Medicare cuts.

Raj Kumar of Stephens asked about the NEMT cost savings program, seeking details on 2024 results and the 2025 outlook. He also requested clarification on the transition to fee-for-service contracts and the expected NEMT margin progression for the year.

Answer

Executive L. Sampson explained that the $35 million in 2024 savings provides an $8-10 million run-rate benefit for 2025, with more cost savings expected. He confirmed 25% of revenue shifted to fee-for-service contracts in Q1. For NEMT margins, he advised modeling a relatively flat year-over-year performance in 2025, with an expected improvement to an 8-10% range entering 2026.