Tenet Healthcare Corp
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Tenet Healthcare Corp
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Good day, everyone, and welcome to the Q4 2017 Tenet Healthcare Earnings Conference Call. My name is Dana, and I'll be your operator for today's call. At this time, all participants are in a listen-only mode. Later, the company will conduct a question-and-answer session.
I would now like to turn the conference over to Brendan Strong, Tenet's Vice President of Investor Relations. Please go ahead.
Good morning. The slides referred to in today's call are posted on the company's website. Please note the cautionary statement on forward-looking information included in the slides. In addition, please note that certain statements made during our discussion today constitute forward-looking statements. These statements relate to future events including, but not limited to, statements with respect to our business outlook and forecasts, our future earnings, and financial position. These forward-looking statements represent management's current expectations based on currently available information as to the outcome and timing of future events but, by their nature, address matters that are uncertain. Actual results and plans could differ materially from those expressed in any forward-looking statement.
For more information, please refer to the risk factors discussed in Tenet's most recent Form 10-K and subsequent SEC filings. Tenet assumes no obligation to update any forward-looking statements or other information that speak as of their respective dates, and you're cautioned not to put undue reliance on these forward-looking statements.
I'll now turn the call over to Ron Rittenmeyer, Tenet's Executive Chairman and Chief Executive Officer.
Thank you, Brendan. Good morning, everyone, and thanks for joining us. Before I pass this on to Dan to discuss the specifics of the fourth quarter, I wanted to take a moment and reflect on the pace of change from both a content and speed perspective.
Slide 3, which begins in late August when I stepped into the role of Executive Chairman, is an illustration of the changes the team has made in not only what we are addressing but how we are establishing priorities. Priorities grounded in improving our financial position to growth and definitive cost initiatives, our capital structure and asset management, our continuation of care and overall quality, and most of all our leadership and talent. While the slide may be a bit crowded, it does capture the cultural change happening throughout the enterprise as we build a sustainable, positive momentum addressing directly the obstacles and challenges we need to face down and resolve. Many of the events listed here are announcements that we made, including senior management changes, improving the composition of the board, implementing a significant cost reduction initiative, initiating the sale process for Conifer, and strengthening our hospital portfolio through divestitures and specific actions to improve quality.
Today, I'm pleased to say quality and safety play a very visible and new level of accountability with everyone whose role crosses these important junctures in dealing with our patients. From a timely and direct review by Eric Evans, President of Hospital Operations, and myself of all serious safety occurrences, to serving as a gatekeeper for participation in the annual bonus program, quality and safety are paramount in our accountability.
What's important from this slide is that these actions are not just brief moments in time. They're about changing the culture by driving improvements in our overall performance, growing our business, developing and adding new talent on a sustainable basis. They're about moving with urgency, refocusing our enterprise and our core business and compliance by building a culture of accountability focused on delivering results.
So how are we doing? I'd like to direct your attention now to slide 4. In terms of quality, we have continued to make improvements in key areas of infection control and overall mortality in our hospitals. Relative to the CMS Overall Quality Star Ratings and inpatient satisfaction, these remain areas where we need further action to improve. Delayering our Hospital Operations management structure and modifying our management incentive compensation program to establish a quality gatekeeper reinforces the importance we have placed on these critical areas. Coupled with that, as I noted at the Investor Conference in January, Eric and I have visited low-performing hospitals to better understand what's not working well as well as the local actions being taken to correct their positions.
We are aligning our support resources to move quickly and decisively to remove all barriers to these important improvements. And by doing so, have realigned roles and responsibilities throughout the organization. There is no ambiguity on accountability for achieving measurable improvements in quality and patient satisfaction. Quality and patient experience are critical drivers of growth over the long-term.
We're also taking actions to reinvigorate growth across each of our business segments. We've continued to work on building out access points to meet patients where they need care. In 2017 we acquired seven surgery centers. We also had 11 de novo additions which included a micro hospital in El Paso, Texas; 2 surgery centers; 7 urgent care centers; and 1 imaging center. These are less capital-intensive, directed to serve local communities close to the patient and provide outpatient care to complement the inpatient care provided by our hospitals.
We are continuing to develop a network to be where the patient is and to provide access to the right level of care with the right level of resources at the right time. Beyond our access points, we are very focused on attracting and retaining an appropriate number of quality physicians in the specialties required to support our service lines. As part of our effort to maximize the power of our enterprise, wide skills, and experience, we have created a combined sales organization which now will be led by Bill Wilcox. The combined structure is aligned with the objectives of having Hospital Operations and Ambulatory working together to grow our overall care delivery business in our markets.
Additionally, I'm conducting a detailed review of our marketing organization to ensure we have the right efforts underway and our message is tailored and being heard in our key markets, verifying that we are effectively presenting ourselves to our communities and patients, allowing them to understand and make an informed decision based on what we offer to solve their needs and underscoring our commitment to quality care and a safe environment. Finally, we need to ensure that we measure and understand whether we are effectively generating a return on the investment we are making across our marketing spend.
While I'm on the subject of growth, I'll touch on performance in the fourth quarter which Dan will get into in more detail. EBITDA was $840 million or roughly $20 million above the high end of our outlook, and EPS was also above our outlook. I was pleased that our hospitals returned to delivering same-hospital volume growth this quarter coupled with improved cost management. In addition, we learned in January that our revenue under the California Provider Fee was going to be greater than what we were anticipating not only in 2017 but for the entire 30-month program which also covers 2018 and the first half of 2019. That's really the key source of upside in the fourth quarter and is captured in our revised outlook for 2018.
Switching over to the Ambulatory segment, we had an excellent quarter. Cases increased 4.6% and revenue per case increased 2.2% while adjusted EBITDA less NCI was up 26.1%. The performance of USPI continues to exceed our expectations and I was very pleased particularly with the strong results in imaging and urgent care visits. In addition, opportunities are ripe on the development side thanks to the hard work of the USPI team, and we completed five new health system joint ventures last year. We are also working with a hospital for special surgery on a new orthopedic care center in West Palm Beach, Florida, which is an important market for us. Looking ahead, we have a robust pipeline and are in discussions with multiple health systems about additional opportunities in 2018 and beyond.
Conifer's results were also ahead of our expectations. Over the past few years, Conifer added many customers and keep customer onboarding results in additional cost which are difficult when adding them to effectively rationalize those costs. This quarter, Conifer did an excellent job in beginning to rationalize these costs. Conifer has, in my view, a task ahead to improve its cost structure by further rationalizing these costs and reducing its footprint with consolidations, and the results this quarter were a very positive start. While EBITDA performance was solid, Conifer's revenues declined year-over-year primarily due to the Tenet divestiture program which does not always result in this part of the business being transferred with a divestiture. Growth is the key driver for service companies, and Conifer has this as its number one priority. While I expect us to tighten cost controls and improve execution, the acquisition of new business is the greater priority.
As you know, we announced in December that we have initiated a process to execute a potential sale of Conifer. As I've said in the past, Conifer is a valuable and attractive asset, and we're very pleased with the level of interest that has been generated. We have started to secure the necessary NDAs and we'll be providing SIM (00:09:29) as we complete those documents. As far as the timeline, it is too early to be specific and as appropriate. We'll make future announcements and that's all the color that we'll be providing on Conifer today.
Cost improvement remains an active process throughout the enterprise. We have great insight and extremely confident on our ability to achieve $125 million in cost savings in 2018 and to exit 2018 with a run rate of $250 million in annualized savings, and I believe we have further opportunity as the year unfolds. One area of savings is coming from the restructuring of our Tenet Physician Resource organization which is the organization responsible for managing our physician clinics and our employed physicians in Tenet. The restructuring of TPR, which took place in the first quarter, eliminated management layers just as we have done in the overall hospital organization and more closely aligns practice to centralize support services. Physician employment and operating physician practice is a very important strategy in terms of serving the medical needs of our communities, but it also involves substantial expense. We need to operate more efficiently in this area, which is why we've already taken these actions.
In regards to other strategic initiatives we discussed, you've seen a series of announcements on our divestiture program over the last few months, which are outlined on slide 5. We've been making solid progress including completing the sale of our Philadelphia hospitals and signing the definitive agreement to sell Des Peres Hospital in St. Louis. In line with our expectations, we anticipate completing the sale of MacNeal in Chicago and the restructuring of our joint venture with Baylor in Dallas in March. We will continue to evaluate individual hospitals and markets based on total cost of ownership and make necessary adjustments dictated by our analysis. Our growth and cost initiatives will be incorporated into these evaluations and we will use hard facts and data as we continue evaluating all assets on a go-forward basis. We remain on track to achieve the $1 billion in proceeds outlined last year.
Before I conclude, I want to touch on the cultural shift taking place at the company. Some of these points are highlighted on slide 6. We've just completed our performance review process for 2017. I will tell you that as I reviewed these ratings, I realized there was a disconnect throughout the organization between how we evaluated individual performance and the overall results we've been delivering in the past. Leadership dictates candor and credibility in rating our talent based on results as well as how they achieve those results. It requires us to take the time to determine if we lack skills, knowledge or execution, and to deal with those deficiencies positively, decisively, and most of all in a timely manner.
My view is we have had a gap in tying results to performance and providing a candid and helpful feedback to our teams, including setting the right level of expectations. Talent development and acquisition demands that we improve this immediately and we are committed to effective performance management at all levels of the organization. I've made a change recently in our HR leadership and I'm working closely with HR and our senior leaders to instill a high accountability culture that is focused on measuring people's performance against concrete goals and objectives. Additionally, in the fourth quarter we added five new senior level leaders in positions to lead change and to ensure we are achieving our commitments. I expect we will continue to assess our leadership through many levels and, where necessary, make appropriate changes.
So with that, I'd like to now turn it over to Dan Cancelmi, our Chief Financial Officer, for a much more detailed review of our fourth quarter performance. Dan?
Thanks, Ron, and good morning, everyone. We generated $840 million of adjusted EBITDA in the fourth quarter, which was above our expectations, resulting in $2.444 billion of adjusted EBITDA for the year. Key sources of upside in the quarter were higher revenue from the California Provider Fee program and strong performance at USPI and Conifer, partially offset by subpar results of facilities we're divesting. Slides 7 and 8 summarizes these and other financial highlights for the quarter and the year, including the growth we achieved in adjusted EBITDA normalized for various items. Adjusted EPS was $0.81 cents in 2017 and $1.40 cents in the fourth quarter.
Our Hospital segment delivered $538 million of EBITDA in the quarter. This included $267 million related to the California Provider Fee program. We delivered strong results in the Ambulatory segment, including adjusted EBITDA less facility-level NCI growth of 26.1%. Conifer produced $79 million of EBITDA in the quarter, $13 million higher than our expectations; and free cash flow was $493 million for the year and $276 million for the quarter, toward the high end of our outlook.
Turning to hospital volumes which are summarized on slide 9, fourth quarter adjusted admissions increased 1.3% and admissions were up 20 basis points. Flu volumes, which were less than 1% of our admissions and outpatient visits in the quarter, added around 20 basis points to overall volume growth in the Hospital segment. Excluding the impact of the sale of our home health and hospice assets last year, outpatient volumes were up 1.9% in the quarter. Looking at the emergency department, volumes were up 4.3%, reversing declines of the last several quarters. On the pricing side, revenue per adjusted admission increased 4.8% in the fourth quarter and was positively impacted by the California Provider Fee. We continue to maintain strong cost controls. Hospital segment expenses per adjusted admission increased just 2.2% for the quarter, and we expect this level of expense discipline to continue in 2018 and 2019 with the help of our cost reduction initiatives.
Turning to slide 10, our bad debt expense was 6.1% of revenue in the quarter compared to 6.8% in the fourth quarter of 2016. Incremental California Provider Fee revenue lowered bad debt expense by roughly 30 basis points. In addition, the combination of hospital divestitures and strong growth in our Ambulatory segment also helped lower bad debt expense as a percentage of revenue.
Moving to our Ambulatory business on slide 11, same-facility case growth was very strong, up 4.6%, yielding same-facility net revenue growth of 6.9%. Volume growth and revenue per case growth in our surgical business were up 2.2% and 4.3% respectively. And the 8.7% growth in visits at our urgent care and imaging centers is the strongest growth rate in our non-surgical business over the past two years.
On slide 12, adjusted EBITDA less facility-level NCI expense increased an impressive 26.1% in the quarter. As we have discussed in the past, the financial results of our Ambulatory business tends to be seasonally stronger in the fourth quarter primarily due to increased surgical demand from commercially insured patients who have met their deductibles.
As you can see on slide 13, Conifer's revenue was down 2% in the quarter and revenue from non-Tenet customers was flat year-over-year. EBITDA was up 9.7% in the quarter due to our cost reduction initiatives.
Turning to slide 14, we raised our outlook for adjusted EBITDA by $25 million to a new range of $2.5 billion to $2.6 billion, which increases the midpoint of our adjusted EPS by 16% to a new range of $0.73 to $1.07. There are a few reasons why we raised our outlook. To start, Conifer's results for the fourth quarter were ahead of our expectations, and we expect this improved performance to carry into 2018. We now anticipate Conifer's 2018 EBITDA to be $10 million higher than we previously expected. Second, the budget legislation that was passed in February included a two-year delay in Medicaid DSH cuts. This change will add $25 million to $30 million to our results this year relative to our prior expectations. It's also worth pointing out that the California Provider Fee revenue is now expected to be around $250 million in 2018, roughly $25 million ahead of our prior expectations. Our revised outlook also reflects a net reduction in estimated EBITDA from facilities we expect to divest this year.
Slide 15 provides additional details on the key components of our outlook by segment, and slide 16 contains an updated EBITDA bridge from our results in 2017 to our outlook for this year. As you can see, we are expecting core growth of 4% to 8% in 2018 which normalizes for divestitures, HITECH, executive severance, and hurricanes. This consists of growth of 1% to 5% in our Hospital segment, 10% to 14% in our Ambulatory segment, and 8% to 12% in our Conifer segment. The combination of organic revenue growth, strong cost controls, and the benefit of acquisitions at USPI will drive improved performance this year.
Our long-term growth expectations are summarized on slide 17. We are reiterating our targets. In our Hospital business, we expect to grow EBITDA by 3% to 5%, with volume growth of 0% to 2%, pricing of 2% to 3%, and from strong cost management, leading to margin expansion in our Hospital business. For our Ambulatory segment, we anticipate delivering long-term EBITDA less facility-level NCI growth of 8% to 10% consisting of 4% to 6% organic growth plus another 4% from acquisitions and de novo development. And for Conifer, we are anticipating that the current market dynamics for revenue cycle and value-based care will support 5% to 7% long-term growth in this segment.
Before I conclude, I want to comment on our cash flows and leverage. In 2017 we generated $493 million of free cash flow. After distributing $258 million to minority partners, we generated $235 million in cash which we used to fund approximately $120 million of acquisitions, substantially all of which were in our Ambulatory segment. This year, we expect to deliver adjusted free cash flow of $675 million to $875 million. We anticipate $50 million to $100 million in cash restructuring payments, resulting in free cash flow of about $625 million to $775 million. We expect to distribute $320 million to $350 million to minority partners this year, leaving us with $300 million to $425 million in cash that we can deploy on acquisitions and our buy up of USPI, which should cost around $290 million, to increase our ownership from 80% today to 87.5%. While there isn't any excess cash up to these investments, it does mean that we will be able to use nearly all of the $700 million-plus of cash from these divestitures on other opportunities this year, including potentially further accelerating our buy up of USPI or debt repayment at or below par depending on trading levels. This is a very meaningful opportunity relative to our market cap.
On leverage, we ended the year at 5.86 times net debt to EBITDA and we continue to target a leverage ratio of 5 times or less by the end of 2019. In summary, we delivered a strong quarter and we're continuing to execute on our cost reduction initiatives, and we raised our outlook for the year.
I'll now turn the call back to Ron who would like to make a few additional remarks before we start Q&A.
Thanks, Dan. The summary slide, which is on slide 18, I think, captures the close. I'm not going to go through all of it. I think we've touched everything on here. But clearly, it's about accountability, focused on the right things including financial performance as well as quality and safety throughout the enterprise. Bringing in the right leadership, developing the leadership we have, dealing with the divestitures in an efficient manner, and continuing to target our 5 times leverage for the end of 2019.
So at that point, Brendan, I'll turn it back to the operator and you.
All right, Dana, we are ready to start Q&A.
Thank you. And we'll go first to Josh Raskin with Nephron Research.
We can't hear you, Josh.
.
Yeah, sorry about that. I guess the first question just I have for you guys is just have you had any direct conversations with employer groups around direct contracting or looking for clinics or things like that? I'm just curious if employers are reaching out to you guys at this point.
Yeah. Josh, this is Eric. We certainly – we've had those conversations periodically for a number of years and then we have those conversations by market regularly. I think there may be a little bit more interest in recent months than in the past, but it's not significant.
Okay. So you're not seeing anything in your local markets at this point?
Well we are – I mean, I think by market we are seeing some opportunities and I do think there could be some strength to that over time. But we're not seeing something that's going to significantly move the needle in the short-term.
This is Ron, and I would say we will be creative and thoughtful about those. We're certainly open to any discussions that could lead to a better outcome.
And then just a second question on the USPI or the Ambulatory segment overall. How much of that EBITDA now is ASCs versus other centers or other outpatient facilities? And then were you looking to invest in one area over the other or is this just sort of a no, we continue to kind of meet the patient where they are and we want to kind of grow everything in that?
This is Bill. Josh, the lion's share of it is on the surgical side with the USPI hospitals and our surgery centers, but the growth opportunities are significant on each of those sectors within the Ambulatory segment. We're seeing a lot of interest on development of additional urgent care centers and also imaging centers both within our Tenet markets and the markets of our health system partners.
Josh, it's Jason. How are you? Just to put a little context on the non-surgical piece of our business, it's about 5% of our earnings. So as Bill mentioned, the vast majority is ASCs and hospitals.
Okay. Even though the growth may be strong there, but it's still just fine. That's what I was looking for. Thanks, Jason.
And the unit dynamics between the surgery business and the non-surgical Ambulatory business are very different in that the – whereas the volumes are not that different, the revenue per volume is about a tenth in the non-surgical part.
Yeah. Okay, great. Thanks, guys.
Thanks, Josh.
And we'll take our next question from Chris Rigg with Deutsche Bank.
Good morning. I just wanted to ask about some of the comments you made around growth, specifically combining the Tenet USPI sales teams. Can you give us a sense or a flavor of what that might do or what the objectives are there? Thanks.
This is Ron. I mean, I'll get Bill to chime in on this as well, but the objective really is that each organization obviously approaches physicians in a different way but there is a knowledge base in terms of how to approach people, the kind of dialogue we want to have. We're here to serve our communities in the most effective manner. And so, Bill, do you have any?
Well just to kind of highlight the conversations that Ron had with you on his prepared comments, there's an intense focus on improving the patient experience and patient safety. That being said, we've got a lot of great facilities. And what we learned at USPI is that when you have those types of quality offerings that the way they're best optimized is through a professional sales management program as opposed to some other approach that we've tried in the past. And so we're going to try that across the entire Tenet enterprise.
Okay, great. And then just on the surgical volumes, obviously the trends in the fourth quarter were quite a bit better than the first three quarters of the year, but volumes were still down. Do you have a sense whether that's just sort of the macro market environment still being soft in the fourth quarter or whether you could do things to sort of gain share over time there? Thanks.
Yes. This is Eric. I think there are a couple of things I would say. Obviously, we continue to see softer volumes than we would like but we're very pleased with the trend improvement in Q4. If you look at – it's the same type of things we're seeing on kind of negative variances, which is lower acuity pain cases, GYN cases we're seeing continuing to migrate to the outpatient world. We do believe that high deductible plans continue to have an impact on timing of when consumers are seeking surgeries. And I'd also say one other thing that kind of shows up in our numbers right now is that with the birth rate and fertility rate being lower last year, that does affect C-section. So if you look at our fourth quarter, for example, about half of our variance was related to OB and C-section.
And so I would just tell you that there's a few things that explain that but we do believe we're making progress. We expect the improving trend to continue. And if you think about the things we're doing to address that, we have over seven hospitals, seven or eight hospitals that are working to raise their trauma levels. We've got a lot of new neuroscientist centers of excellence and comprehensive stroke centers coming on line. So, again, raising the acuity of our facilities, being a provider of higher acuity services that we think often are a source, obviously, of those higher acuity surgeries. And then working closely with both teams to make sure that that stuff is transitioning in our markets, that we're able to earn that business no matter where the patient seeks it.
Okay. Thanks a lot.
And we'll take our next question from A.J. Rice with Credit Suisse.
Hi, everybody. Maybe just following-up on that volume question. So if I look at your inpatient admissions, you've had I guess four straight quarters where they were negative. You're slightly positive in the fourth quarter, 20 basis points. I hear what Chris is asking about on the surgery side, but there must have been something that was positive. Is that new service additions or is there something else going on there?
And then I guess on the 2.2% increase in the surgical case volumes in the Ambulatory division, that's the first positive in a couple of quarters there. We were sort of surprised you have the two negative quarters, but anything to highlight? And is that referring your own business as you're describing it out of the hospital-based surgery centers into the freestanding or is there something else going on there?
So I'll start with your inpatient question. We were certainly pleased to obviously take the brackets off our growth on inpatient. Our expectation is to continue to grow that business. There's a few things that are happening. I think you're right to point out we had a number of new investments that are maturing, a new hospital in El Paso that's been ramping up nicely, the new tower at Delray Medical Center which has had a really nice start, and of course our expansion in Detroit. So we think all those things are certainly helping with that.
And then it's really our focus on service line excellence, the six service lines we talk about a lot: cardio, ortho, neuro, behavioral health, trauma, and rehab. And so we are continuing to focus on those and differentiate our product, and our goal there is to take market share. So we have to find ways to continue to do that and we feel like we're making progress. Jason, go ahead.
Yeah. A.J., this is Jason. I'll start by saying the growth in the fourth quarter is not cannibalization of hospital volumes, and it's pretty consistent with our long-term view of case growth. Obviously, the third quarter was impacted by the storms. As you know, we're increasingly seasonal so we get a little pickup in the fourth quarter, but 2% is about where we expect to be long-term.
And one other thing I'd just throw on there too that I didn't mention – is we continue to talk about our investment in access points and making sure that we're across the continuum, and I think that strategy continues to be an important one for us as we try to meet the consumers' needs and make sure that we're able to earn their business at every point along the continuum.
Okay, and then maybe if I could just quickly ask about the cost-cutting program. I appreciate the slide that lays out by division how much you think you'll pick up to get to your target for savings this year, and then also the comment in the prepared remarks that you'd exit the year with about $250 million of run rate of savings, so obviously that suggests a step-up as the year progresses. I guess I'm trying to understand what is in-hand now, what sort of is still yet to come to realize those savings, and if there's a way to highlight a couple of key elements to those savings.
Good morning, A.J., this is Dan. Let me try to address that. Certainly, a couple of things come to mind when you think about what's already in-hand. So we've eliminated several management layers on the Hospital side, previously our regional leadership. As Ron mentioned in his remarks, we're also now looking at our physician organization structure, and there's overhead costs in there that we have concluded aren't necessarily on the long-term basis so we'll be making adjustments there. We've been looking at our corporate overhead levels over the past year, and we'll continue to do that this year and beyond. And so we're removing costs there, looking for ways to be more efficient, work smarter. And then when you think about some of the other business units, Conifer is off to a really strong start in terms of their cost initiatives. We have a new COO there who you may remember. Kyle Burtnett has come in, got off to a really fast start. And USPI as well; they've identified a number of cost actions, some of which we've begun to capture already, but more to come in 2018. We feel very comfortable with our estimates at this point and leaving this year with a run rate of $250 million.
This is Ron. The only other comment I'd add is that we are – this is not like a one-time effort. Part of how you rebuild the fabric of the company is to be thinking about opportunities all the time, to be questioning whether or not the steps we take are necessary. Are there more efficient ways to do things, where automation fits in, where technology fits in, how does your investment pay itself back. So I think we're being generally very attuned to this across the board at every level and we're going deeper into the organization, which I think has been both interesting and a learning experience. And we are, I think, in many ways, will – this'll be part of our culture going forward, is to look for ways to operate in a more effective manner.
Okay. Thanks a lot.
And we'll go next to Kevin Fischbeck with Bank of America Merrill Lynch.
Great. Thanks. I wanted to go into your volume guidance for 2018. You're looking for, I guess, 0% to 2% distribution growth. I think that Humana in 2017, if I kind of add up what you guys said across the quarters, it's probably about a 1% kind of headwind to volumes in 2017. So is the core number the right way to think about it for 2018, something more like negative 1% to plus 1% on the Hospital side?
Hey, Kevin, it's Dan. Good morning. In terms – so our overall volume growth that we're targeting this year is 0% to 2%. In terms of Humana, certainly there is some additional business that we're going to have back this year compared to last year. Some of the business from an exchange perspective isn't necessarily Humana's book of business anymore and would potentially be with other exchange plans. But, yeah, there's certainly some of Humana lift on a year-over-year basis in our volume. Certainly, it was nice to see positive trends in the fourth quarter. We're working it. Growth is certainly a key part of the focus here and in terms of driving improved performance on the Hospital side.
Okay. And then I guess the pricing number, 1.5% to 2.5% for 2018, I guess can you break that out I guess by the payer there? I guess I'm surprised that the number is as low as that typically given the fact that you guys, I assume, will be talking a lot about driving high acuity volumes. I would've thought that there would've been maybe a little bit more of a lift there. Is there anything in there around payer mix I guess maybe going the wrong way as an offset?
Yeah. A couple of the key drivers. So from a commercial perspective, we think that's probably around 4% or so. Medicare is essentially flat on the inpatient side. There is lift on the outpatient side. There are a couple of things that are – some Medicaid reductions that commenced in the back half of last year. So incremental Medicaid reductions in Florida and Texas, that'll be a hurdle we'll have to get over this year. But I think how you should think about it is essentially flat on the Medicare inpatient side, outpatient up a bit, Medicaid down slightly, and in commercial around 4%.
Okay, and about mix?
From a mix perspective, I don't think there's any material change in the mix that we're seeing at this point year-over-year.
All right. Thank you.
And we'll take our next question from Sarah James with Piper Jaffray.
Thank you. I wanted to clarify something on the 4Q same-store revenue per admission. If we back out the California Provider Fee program, was it really a negative 0.4% trend and is there any impact to 2018 assumed from that?
Sarah, it's Dan, let me address that. Good morning. Really, there's several things. One, as we've talked about, our surgical volumes aren't where they need to be. And as you know, surgical business has a higher yield on a per encounter basis, so that's a part of it. Two, the volumes in the fourth quarter, there was an increase in some of the lower acuity business such as flu which, as you know, has a lower revenue yield on a per patient type of basis as well. And then when you think about Q4 2017 versus 2016, there was various reductions and certain reimbursement rates that kicked in. For example, the Medicare cuts, the DSH cuts, they kicked in in the fourth quarter of last year. We also had, again, the Florida and Texas Medicaid reductions on a year-over-year basis and some other Medicaid reductions that account for 150 to 200 basis points. So when you normalize for some of those things, it is growth year-over-year. But again, we need to drive growth in our surgical volumes. That takes care of a lot of the revenue yield issues.
Got it. Thank you. And then just touching on upcoming divestitures, it looks like the adjusted EBITDA range is creeping up in what you're divesting. And I wanted to better understand if that's a Tenet choice or if it's more where the market is now? There's just more demand for higher-quality assets and how that's affecting the valuation that you're getting for those divested assets?
Sarah, this is Brendan Strong. I'll start. On one of the slides, we talk about a trailing 12-month revenue of $1.9 billion and about $75 million, so roughly a 4% margin which is where we were. So I just wanted to mention that, and I'll turn it over to Keith.
I'm not sure about the math either I guess to follow-up on Brendan that you have there. But we certainly are active on every one of the remaining assets that we haven't already announced a definitive agreement. And in general, we've been achieving the same range of multiples. Some of them may not be as meaningful because there isn't a lot of EBITDA but the same multiple certainly of EBITDA that we have on some of the earlier divestitures. So we haven't really seen any material change there and so we don't expect any material change as we finish out the divestitures that we have on slide 5.
Got it. Thank you and will follow-up after the call.
And we'll take our next question from Steve Tanal with Goldman Sachs.
Good morning, guys. Thanks for taking my question. I guess just to follow-up on I think Sarah's question, what I was hoping to understand is the portion of the California Provider Fee that was not attributable to the fourth quarter that was collected. The impact of that, if you just isolate what was sort of normalized, and think about provisions on that basis and revenue per adjusted admission, any color there would be pretty helpful for us.
Yeah. Steve, it's Dan. Good morning. The revenue yield in the quarter was up 4.8%. If you normalize for the incremental $200 million on a year-over-year basis of California revenue, the revenue yield was down about 30 bps, okay? And as I mentioned to Sarah, when you take into consideration the Medicare cuts that went to effect in the fourth quarter, the Florida and Texas and other Medicaid cuts, and the lower acuity business such as flu business, that's what's having the impact. If you normalize for those type of things, you do have positive revenue growth. But again, it's also impacted by our surgical volumes are down 2.9% year-over-year. So that has an impact, too.
Got it. So just to be clear, I guess the full amount of the California Provider Fee, the $200 million, is the incremental amount not attributable to the quarter I guess is a takeaway there for me, but just one other, too. The other OpEx line specifically looked really well-contained versus the way we've been modeling it, and I wonder if you can call out any sort of the drivers inside of that line. What was good there, and I'll yield. Thank you.
Yeah. So certainly, we've been going in as part of our cost efforts, going in, looking at vendor spend across the board; rationalizing vendors where we have multiple vendors to try to drive improved SLA performance, cost efficiencies – you name it. And in terms of how we look at expenses, it's certainly an area where we've had a lot of focus over the past several years. Our expenses overall, we're pretty pleased where we came in for the year. Expenses were up 2% on an aggregate basis for the year. You may remember, when we started the year our range was 2.5% to 3.5% growth. So we came in below our initial range for the year and it's pretty much across the board in terms of salaries and supplies, was only up 10 basis points for the year. The other operating expense line, I would say it can move around a little bit based on malpractice type of cases that we may decide to settle. So from quarter-to-quarter it can move a little bit but there's a spend certainly in that other operating expense line that we're going to continue to go after, and certainly that's part of the $250 million cost reduction initiative program that we're focused on.
Got it. Okay. Thank you.
We'll go next to Ana Gupte with Leerink Partners.
Hi. Thanks. Good morning. Wanted to follow-up on the ED (00:45:55) reversal you had pretty weak upon the first three quarters. Can you give us some color around how much of that was structural because of mix shifting to low-cost access points or was it more a comps issue on exchanges? And then when you saw this big reversal to the positive in the fourth quarter, how much of that is flu-related? And then if you look into the first quarter, how much of that is going to sustainably – a reversal structurally for yourself and any thoughts on the industry comp trends here?
Good morning, Ana, it's Dan. One thing that certainly had an impact on that line was the flu volumes in the quarter, and that was probably, I don't know, a 70, 80-basis point impact. But certainly, the negative trends did reverse. Eric, I don't know if you want to add a couple points.
Yeah, no, I think Dan's right. Certainly, flu had an impact. But I'd also say we think it's getting back to a more normalized trend. And certainly, our access point strategy and maturing access points across the system had an impact on that as well. We saw significant growth in our micro hospitals and freestanding – our off-campus ERs. And not just there; as you heard earlier too, we saw significant growth in urgent care centers. So having those access points available in the right places to meet the patient where they want to be treated is a huge part of this as well, and we're going to continue to focus on that. And hopefully we'll continue to have positive growth in the year.
Okay, thanks. One question on USPI. It looks like you have about 6.5% of your EBITDA coming from M&A and de novo in 2018. What is the expected rate of growth going forward given the CapEx that you're investing now in 2018 looking into 2019? And then any color on the assets available and multiples and the competitive dynamic around acquisitions there?
Hey. Ana, this is Jason. How are you?
Hi, Jason.
Okay. I think what we've said is you can expect about 4% growth from M&A, so we had 4% to 6% organic growth and then 4% on top of that from M&A. And then as to the pipeline, we've talked about for a few years now anticipating spending $100 million to $150 million each year on M&A, and we've got a pipeline right now that is strong as it ever has been and certainly supports that level of growth.
Got it. Thank you.
And we'll go next to Brian Tanquilut with Jefferies.
Hey, guys. This is Jason Byron (00:48:43) on for Brian. Another question on the ASC. So any color you could provide on trends in acuity versus peer pricing, what you saw in Q4? And then kind of what you're expecting for those two drivers in 2018 would be helpful.
This is Bill. The drivers of the net revenue per case being as robust as they currently are is almost entirely complexity. We do continue to have a better payer degradation shifting from commercial to government, and that's been relatively consistent, and it's offset by just routine inflationary type of increases. The specialty mix is generally static, so we're seeing a large move from inpatient to our HOPDs, hospital outpatient departments, and also from the hospital outpatient departments to ASCs. Not move in cases necessarily but a move in the intensity of the cases that are being done in those settings.
Great. That's it for me.
And we'll go next to John Ransom with Raymond James.
Hey. Good morning. Just going back to the hospital divestitures and Conifer. As you're talking to potential buyers of Conifer, what's the message on Tenet's commitment to those remaining hospitals? Are we looking at kind of the final set of assets or do you think that we could have another range of divestitures? And I would assume that would kind of factor the valuation you would get.
This is Ron. I think what we said on the slide also was that this is a continuation, right? I mean, we're going to continue this evaluation. Things change. We obviously have a good set of assets but there is no guarantee that we will not continue to move up against others. We're on the bubble of we question whether or not we're as effective as we could be in any given market. So in my view, those things are always open for discussion. It's something we look at I'd say on the continuum without question. And we look at the total cost of ownership, which is pretty important as well, so we understand what's our capital investment over some period of time and whether or not we're getting the right return. So Keith, do you want to add anything there?
Yeah. John, just a couple of things. One is some of the divestitures, we're actually keeping new – we're getting new commercial contracts. And if you look at our 2018 guidance for Conifer, it incorporates the impact of the remaining portion of this divestiture program in it. So there continues to be a lot of improvements at Conifer and other growth that can overcome a little bit of that. So I think we're being very transparent on the impact of divestitures, and they'll be built in to the model and they're already in your 2018 guidance that we updated today.
And do you think you'll come back to the market in a quarter and say this is our targeted cost savings for Conifer or is it just going to be kind of into the overall because it sounds to me like you've got some more opportunity there that's not embedded in your current guidance.
I think that we will. I don't know if we'll come back with the specific thing since we're in a sale process, but we've got to be careful how the lines cross here as we're going through this. So I can just make the comment that Steve is sitting right here, but I would say that we are very, very acutely aware of the opportunities yet that we're still unraveling. So Steve, do you want to?
Yeah. John, I mean, as we talked about over the past couple of years, we've made synonymous improvements in our operations and we're spending money on that, and those things are starting to pay off here as we moved out of 2017, which we saw obviously strong performance in this fourth quarter. We expect that to continue in 2018 but there are things that are damaged and some of them we're looking at things like consolidation. I mean, there's obviously the massive growth we had over the last several years required us to have – we have operations in places we necessarily don't all need them, so we're looking at that from a consolidation standpoint which allows cost savings. We do kind of an onshore/offshore blend, looking at opportunities as far as that's concerned. We do other things in other places as far as that. So looking at delayering things, you would expect overall operation performance, looking at technology, robotics and the like into our performance operation. So I think you should just expect obviously us to continue to drive the cost structure through 2018.
But I'd also close by just saying – let me just close on that question by saying that make no mistake, we're very specific about what we want done, and we're very – we're spending a lot of time looking at specific actions. So it's just the sale process. I think you've got to be a little thoughtful about what we come back within an entire group. But sales process or not, we're not backing off at all on driving improved performance at Conifer. So we're going to treat it just like what it is, an ongoing business for us, and we're going to try to maximize our returns.
And just lastly for me, what do you think – when you're talking to potential buyers, what do you tell them in terms of this is how big this market could be, this is our market share and these are our market share trends because I know you've got some new competition here, and I'd be curious to know if you think you're holding your own or if you're maybe losing a little bit of share, and kind of what inning we're in with taking revenue cycle to more of your – to more of the hospital industry.
I would just tell you that I think we believe we're growing and that we have opportunities in front of us and we're working on them. This is, again, somewhat a difficult conversation to have when we're just engaged in the middle of just entering a sale process. So all I would tell you is that to me, services businesses, as I said in my comments, they need growth and they need new opportunities. Steve and his team are absolutely engaged in doing that and we get it and we have to go out and make it work. So we're pretty engaged in that and I feel comfortable with our pipeline and where we're heading.
All right. Thank you. That's it for me.
And we'll go next to Gary Taylor with JPMorgan.
Hey. Good morning. Two-part question. The first just on the Ambulatory side where you did very well this quarter, and I just wanted to explore this role of seasonality a little bit more where you've talked about increased copay deductibles. Maybe that's shifting demand later in the year where people have already met those. Is that an intuitive conclusion or do you have some data that shows this year versus last year patient balance after was X percent of the bill versus a year ago or something that sort of quantifies that because intuitively it certainly could argue for being a driver of some of this better growth. But last year, 4Q was the weakest growth so it didn't seem to be a driver. So I just wondered if there was maybe some way to quantify whether that is continuing to shift seasonality throughout the year.
Sure. Gary, this is Jason. I'll start by saying last year you may recall that we talked about what a steep comp we had in 2015 where we had growth over 5%. So to say last year was slow, it was slower than this year but on a much heavier comp. We do – obviously because we mostly collect prior to the data service, we know patient balance after a case is higher in Q1 and earlier in the year than it is Q4. So it is something demonstrable. I don't think we've publicly put out stats about patient collection balances by quarter or term, but it is something that's real and I hope that answered your question.
Yeah. 4Q-over-4Q, you still think that's moving somewhat. That hasn't yet stabilized it sounds like.
We think – Yeah, we think we're still – our seasonality is increasing, I'll say it that way.
Okay.
And that continues.
And then second, just moving to the Hospital side where it wasn't as strong where – I guess we're looking ex the California Fee same-store revenue up a little less than 1% year-over-year in a quarter where you've got a really strong flu season and Humana coming back in that work. One of the things you had touched on was some of the held-for-sale assets maybe underperforming a little bit here. When we think about kind of the continuing base of hospitals or the hospitals that will remain in continuing operations, I mean, can you point to a same-store revenue growth number in the 4Q that's materially better than 1%? Does it look quite differentiated?
Yeah. One second, Gary. Dan's mic is not turning on. Sorry.
Okay.
Here. One second.
Hey, Gary, it's Dan. Sorry about that, mic wouldn't turn on. No, from a hospital perspective in the fourth quarter, in terms of – when you normalize for the incremental California revenue above our initial expectations, I would really point to two things in terms of the Hospital results in the quarter. One, the performance of certain of the hospitals that we're selling just came in below what we anticipated where they were going to be. Certainly, we're putting resources in to continue to enhance the organizations until they are divested. But their performance in aggregate was a pretty big negative driver as well as we did have some incremental medical malpractice costs in the quarter. We decided to settle some claims, but I would point to just the overall performance in the hospitals that we're selling.
Now, we need to adjust for those. The rest of the Hospital business was pretty strong in the quarter, but certainly some of the results at these facilities and the extra med mal sort of brought the numbers down. But listen, we're obviously pleased. We're back at positive volume growth in the quarter. That's what we're targeting this year, and we're targeting a nice growth in the margin in the Hospital segment from about 9% to a little over 10%.
Is there any chance I could get you to quantify is that pretty strong?
Well when you take into consideration the results of the divested facilities as well as the incremental med mal, we were actually ahead of our expectations for the quarter from a Hospital perspective.
Yeah. Okay. Thank you.
And due to time constraints, we'll take our final question today from Frank Morgan with RBC Capital Markets.
Good morning. I think you've sort of answered this and I want to go back one more time to make sure I got it right. But in terms of – I think you attributed most of the pricing growth in the USPI business to purely intensity. But was it there was just no improvement at all in the commercial patient mix going from third quarter to fourth quarter? I know a lot of folks had probably expected that the commercial mix to improve by year-end, but is that not the case and it was just purely intensity?
Hey, Frank, this is Jason. No, I'm sorry, let me clarify that. Although a lot of our growth, looking at the full year, is from shifts in complexity within specialties like orthopedics and spine, we definitely do see a spike at year-end in commercial mix relative to the rest of the year. So that is a driver in the fourth quarter for us.
Okay. And I noticed within that division, obviously urgent care – good volume growth there. But how different is the revenue mix in urgent care, say, versus surgery? Is it more commercial? And any changes in the dynamics there?
Frank, it is, again, just for context there because it skews the volume stats, but it's about 5% of our earnings. But you're right; we see a heavier commercial and self-pay mix in the urgent care business than we do on the surgery side where the government mix on surgery is about 0.25%.
Got you, one final question. Just obviously you called out the need to improve volume and yield. You needed more surgical volumes and the benefit of some of these service line expansions you're talking about to increase market share, but are there any specific markets that you can call out where you're already starting to see success? And then maybe just some general commentary off from a regional perspective across your markets, any particular markets that you would specifically call out doing better or worse? Thank you.
Hey, Frank, it's Dan. Certainly, we've had success in certain markets from a surgical perspective. But in aggregate, we're still down or close to 3% in the quarter. There was a couple of markets that were key drivers of that. We're focused on that. But it's overall – let's be clear here. We want to drive improved surgical volumes across the board even though there may be one or two markets that were key drivers of it in the quarter. We need to be better overall across the Hospital portfolio.
Yeah. And to add just a little color to that, I mean I would say we could point to a couple markets that made up the entire variance, and we certainly have very strong plans in place for those. So we certainly have identified where we have the biggest opportunities and we're cracking to improve those numbers as we move through 2018.
Thanks a lot, Frank.
And Dana, that concludes the call.
Thank you, and we would like to thank everybody for their participation. You may now disconnect.