HCA Healthcare Q3 2021 Earnings Report

HCA Healthcare EPS Results

• Actual EPS: $4.57
• Consensus EPS: $4.10
• Beat/Miss: Beat by +$0.47
• One Year Ago EPS: $1.92

HCA Healthcare Revenue Results

• Actual Revenue: $15.28 billion
• Expected Revenue: $14.51 billion
• Beat/Miss: Beat by +$764.90 million
• YoY Revenue Growth: +14.80%

HCA Healthcare Announcement Details

• Quarter: Q3 2021
• Date: 10/21/2021
• Time: Before Market Opens
• Conference Call Date: Thursday, October 21, 2021
• Conference Call Time: 8:00PM ET

HCA Healthcare (NYSE:HCA) is a for‑profit operator of healthcare facilities headquartered in Nashville, Tennessee. Founded in 1968, the company owns and operates a network of hospitals and related healthcare facilities and has grown through organic expansion and acquisitions to become a large provider of inpatient and outpatient services.

The company's core activities include the operation of acute care hospitals, freestanding surgical and emergency centers, and outpatient clinics. HCA's services encompass inpatient care, surgical services, emergency medicine, diagnostic imaging and laboratory testing, and various outpatient and ambulatory care offerings. The organization also supports physician practices and provides management and administrative services to its clinical operations.

HCA Healthcare serves patients primarily across the United States and maintains a presence in the United Kingdom through its international operations. The company participates in clinical education and training programs, and it invests in health information technology, quality improvement initiatives and care coordination to support clinical outcomes and operational efficiency.

Headquartered in Nashville, HCA is led by senior management focused on integrating clinical care with operational and technological capabilities. The company's strategy emphasizes delivering a broad continuum of care across inpatient and outpatient settings while pursuing partnerships and initiatives that support clinical quality, access and cost management.

HCA Healthcare Q3 2021 Earnings Call Transcript

Key Takeaways

• HCA Healthcare delivered 15% revenue growth year-over-year in Q3, with inpatient revenue up 18% and outpatient revenue up 11%, driving a record adjusted EBITDA margin above 21% and diluted EPS of $4.57.
• The company has raised its full-year 2021 earnings guidance again, reflecting strong Q3 performance and record levels of inpatient share.
• Looking ahead to 2022, HCA expects volumes to grow 2%–3% and COVID admissions to represent 3%–5% of total admissions, projecting modest adjusted EBITDA growth despite anticipated cuts to pandemic-related government reimbursement.
• Q3 labor costs rose sharply amid the delta surge due to premium pay, shift bonuses and contract staffing, and HCA is expanding its Galen School of Nursing, enhancing recruitment and applying care transformation initiatives to manage ongoing labor challenges.
• Through Q3, HCA repurchased $2.3 billion in shares, expects to complete $8 billion of buybacks in 2021, and ended the quarter with a debt-to-EBITDA ratio of 2.55x and $5.9 billion of available liquidity after divesting four hospitals.

Presentation

[Operator]

Welcome to the HCA Healthcare Third Quarter 2021 Earnings Conference Call. Today's call is being recorded. At this time, for opening remarks and introductions, I would like to turn the call over to the Vice President of Investor Relations, Mr. Mark Kimbrough. Please go ahead, sir.

[Mark Kimbrough, VP of Investor Relations at HCA Healthcare]

All right, Chris. Thank you so much. Good morning and welcome to everyone on today's call. With me this morning is our Chief Executive Officer, Sam Hazen, and Chief Financial Officer, Bill Rutherford. Sam and Bill will provide some prepared remarks, and then we'll take questions. Before I turn the call over to Sam and Bill, let me remind everyone that should today's call contain any forward-looking statements, they are based on management's current expectations. Numerous risks, uncertainties, and other factors may cause actual results to differ materially from those that might be expressed today. More information on forward-looking statements and these factors are listed in today's press release and in our various SEC filings.

[Mark Kimbrough, VP of Investor Relations at HCA Healthcare]

On this morning's call, we may reference measures such as adjusted EBITDA, which is a non-GAAP financial measure. The table providing supplemental information on adjusted EBITDA and reconciling net income attributable to HCA Healthcare, Inc. is included in today's release. This morning's call is being recorded and a replay of the call will be available later today. With that, I'll turn the call over to Sam. Sam?

[Sam Hazen, CEO at HCA Healthcare]

Good morning, and thank you for joining us. The third quarter is the most intense period yet for us with the COVID pandemic. The Delta variant surged and drove significant demand for our services. Quarter-to-quarter, COVID patients accounted for 13% of total admissions. This level compares to 3% in the second quarter, 10% in the first quarter, and 11% in the fourth quarter of last year. Our teams provided record levels of inpatient care during the quarter. This drove revenue growth of 15% as compared to the prior year. Inpatient revenue grew 18% and outpatient revenue grew to 11%. As compared to prior year, and also 2019, same-facility volumes increased across all patient categories with the exception of inpatient surgery. Surgery volumes were constrained because capacity was used for treating COVID patients.

[Sam Hazen, CEO at HCA Healthcare]

This growth was supported by a better payer mix of commercial business. Adjusted EBITDA margin was strong at over 21%. Diluted earnings per share, excluding gains on sales of facilities, increased to $4.57, which is a notable increase over the prior year, even considering that last year's third quarter included a $1.72 per share effect of the reversal of the government stimulus income, which as you may recall, resulted from our decision to return or repay early approximately $6 billion of governmental assistance we received from the CARES Act. Once again, our colleagues and physicians delivered for our patients and for our communities. I'm tremendously proud of their dedication and service to others, and want to thank them for their great work.

[Sam Hazen, CEO at HCA Healthcare]

As we look to the remainder of 2021, we have raised our annual earnings guidance again to reflect the strong performance of the company. Now let me transition to some early and general perspectives on the upcoming year. Just like in 2020, we are providing some preliminary thoughts in the midst of a very fluid environment, which obviously makes it challenging given the uncertainties that continue to exist with the pandemic. We plan to provide more details with our annual guidance in January after we complete our planning process for 2022.

[Sam Hazen, CEO at HCA Healthcare]

By that time, we hope to have a few more months of results that are more indicative of a normal operating environment. That is, a non-COVID surge environment to analyze and give you a better indication of our business. Overall, we believe demand will return to historical trends for us, with volumes growing across most categories in the 2%-3% zone. As part of this growth, we expect to treat COVID patients throughout 2022. We estimate that approximately 3%-5% of our total admissions will be COVID-related.

[Sam Hazen, CEO at HCA Healthcare]

We believe our business will be supported by a strong payer mix as a result of stable enrollment in the health insurance exchanges and good job growth across our markets. We are also assuming patient acuity continues at high levels. We do expect certain pandemic-related governmental reimbursement programs either will not continue or will continue, but at significantly reduced amounts next year. However, we anticipate the reduction of these revenues to be partially offset by certain costs we incurred in treating COVID patients. Clearly, we are operating in a challenging labor environment, which we expect to cause some cost pressures. At this point in time, we anticipate being able to manage through these challenges along with other inflationary cost pressures.

[Sam Hazen, CEO at HCA Healthcare]

In sum, these assumptions lead us to believe that adjusted EBITDA for 2022 will show modest growth over this year's estimated results. Again, we are providing early perspectives and expectations, and they could change. The past two years have been a remarkable period for HCA Healthcare. We have demonstrated a high level of resiliency and resolve, while at the same time staying true to our mission. Across many dimensions of our business, we have improved our operational and organizational capabilities, which should allow us to provide higher quality care to our patients. I also believe we will emerge on the backside of this event stronger financially and better positioned competitively to grow and drive value for our stakeholders.

[Sam Hazen, CEO at HCA Healthcare]

We are investing aggressively in our operating model, which is to develop a comprehensive and conveniently located local network coupled with and supported by an enterprise-level system with unique scale and system-level capabilities. We believe this model creates competitive advantage, drives market share gains, and produces better outcomes for our stakeholders. With that, I'll turn the call over to Bill. Thank you.

[Bill Rutherford, CFO at HCA Healthcare]

Great. Thank you, Sam, good morning, everyone. I will discuss the cash flow and capital allocation activity during the quarter, then review our updated 2021 guidance. Our cash flow from operations was $2.28 billion as compared to $2.7 billion in the third quarter of 2020. In the prior year, we had received approximately $300 million of stimulus income and deferred approximately $200 million of payroll taxes. Capital spending for the quarter was $889 million, and we have approximately $3.9 billion of approved capital in the pipeline that is scheduled to come online between now and the end of 2023. We completed just over $2.3 billion of share repurchases during the quarter. We have approximately $2.7 billion remaining on our authorization, and we anticipate completing approximately $8 billion of share repurchases for full year 2021.

[Bill Rutherford, CFO at HCA Healthcare]

Our debt to EBITDA ratio was 2.55x at the end of the third quarter, which is the lowest it has been in over 15 years. We had approximately $5.9 billion of available liquidity at the end of the quarter. Also during the quarter, we recorded about $1 billion gain on sale of facilities related to the sale of four hospitals in Georgia and other healthcare entity investments. We anticipate we will generate approximately $1.5 billion of after-tax proceeds from our announced divestitures. As noted in our release this morning, we are updating our full year 2021 guidance as follows. We now expect revenues to range between $58.7 billion and $59.3 billion. We expect full year adjusted EBITDA to range between $12.5 billion and $12.8 billion. We expect full year diluted earnings per share to range between $17.20 and $17.80.

[Bill Rutherford, CFO at HCA Healthcare]

Our capital spending target remains at approximately $3.7 billion. As I conclude my remarks, I think it's important to reflect on the financial condition of the company as we have navigated the past 20 months of this pandemic. The financial resiliency of HCA Healthcare has been on full display during this time. Our organization has emerged stronger today than before we entered this pandemic. With our leverage ratio well below the low end of our stated range of 3x, our available liquidity, and our continued strong cash flow generation, we are well positioned as we evaluate capital allocation opportunities heading into our planning cycle for 2022. Look forward to sharing more information with you about our outlook in our year-end call. With that, I'll turn the call over to Mark to open it up for Q&A.

[Mark Kimbrough, VP of Investor Relations at HCA Healthcare]

All right. Thanks, Sam. Thank you, Bill. Chris, would you give instructions on getting into the queue for questions, please?

[Operator]

Certainly. At this time, if you'd like to ask a question, please press star, then the number one on your telephone keypad, and we'll pause for just a moment to conduct the Q&A roster. Again, star one to ask a question.

[Mark Kimbrough, VP of Investor Relations at HCA Healthcare]

I'd like to remind everyone also to try to keep the questions to one so that we can try to get as many people in the queue as possible.

[Operator]

The first question is from Kevin Fischbeck with Bank of America. Your line is open.

[Kevin Fischbeck, Senior Research Analyst at BofA Securities]

Great. Sorry, I have a question for clarification and then a main question. Did you say that at 2%-3% volume growth in total or across most service lines? It sounds like COVID volume might actually be down next year, so I just want to make sure I was hearing that right. The main question is really about labor costs. It does seem like labor is higher than we thought this quarter. Q4 looks like the margins may be a bit lower than we thought. Just a little more color on how you're managing labor and what kind of growth are you seeing there today?

[Sam Hazen, CEO at HCA Healthcare]

I shouldn't hear what he said the first question was.

[Bill Rutherford, CFO at HCA Healthcare]

Volume. When we hope 2%-3% on the volume, was that all inclusive or just across service lines?

[Kevin Fischbeck, Senior Research Analyst at BofA Securities]

Yeah, because COVID is down, right? Important to understand 2%-3% and COVID down.

[Sam Hazen, CEO at HCA Healthcare]

We expect COVID volumes to be down. As I said, we are anticipating 3%-5% of our total admissions will be COVID related next year. It's about 9%, I think, for this year. That we do expect some decline in COVID related. We hope that happens for our communities and so forth. When we estimate at this particular point in time, we're expecting composite volumes across the company as a whole to be up in the 2%-3% zone. Over 2020 and over 2019 is really what it boils down to.

[Kevin Fischbeck, Senior Research Analyst at BofA Securities]

Yeah. Labor?

[Sam Hazen, CEO at HCA Healthcare]

Yeah, on labor, let me speak to labor. Obviously, in the third quarter, we were dealing with a very intense COVID surge with very sick patients, and it was putting a significant strain on our communities and on our facilities and so forth. We did what we absolutely had to do as a moral imperative to take care of people. That required us to support that volume and that level of acuity with labor. Our labor costs did step up in the third quarter. We used premium pay where we needed to. We used different levels of shift bonuses and overtime where we needed to, but that was not a question to us. We had a lot of people to take care of, and we took care of them appropriately.

[Sam Hazen, CEO at HCA Healthcare]

We still produced, I think, a very good outcome for the company, with margins at over 21% in the third quarter and actually producing record EBITDA levels. Labor going forward, we have a multi-pronged strategy for managing. It starts with expanding our school of nursing, which we think is going to produce a great pipeline of graduate nurses for our company. We anticipate approximately three times the number of graduates coming out of the Galen College of Nursing over the next few years compared to what we do today. The second thing we're working on is recruitment and retention, and we've added tremendous amount of resources to our recruitment functions.

[Sam Hazen, CEO at HCA Healthcare]

We've advanced our benefits in many areas, and we're trying to create an environment where our nurses can accomplish what they need to do with our patients and ultimately have an environment where they can be tremendously successful in discharging their responsibilities to our patients. At the same time, more productive in doing just nursing care as opposed to non-nursing care. The last thing we're working on that we're very excited about is care transformation. We think we have opportunities with technology and with new models of care and different levels of support that can change the paradigm in how we deliver care on our floors at our hospitals. We think the combination of all three of these things put us in a position where we can manage through the environment that we're facing right now. Obviously, there's some unknowns.

[Sam Hazen, CEO at HCA Healthcare]

We're going to have to work our way through those as they present themselves. We're pretty confident that the company is in a reasonable position to manage through the labor environment.

[Mark Kimbrough, VP of Investor Relations at HCA Healthcare]

Kevin, thank you. Chris, next question, please.

[Operator]

The next question is from Ann Hynes with Mizuho Securities. Your line is open.

[Ann Hynes, Senior Healthcare Services Equity Analyst and Managing Director at Mizuho Securities]

Hi, good morning.

[Ann Hynes, Senior Healthcare Services Equity Analyst and Managing Director at Mizuho Securities]

I just want to know how volume tracked by payer mix is commercial still outperforming Medicare and Medicaid, and what your expectations are for 2022 when it comes to payer mix? Just one follow-up on your comment about inpatient surgeries being down. If you look at the chart you provided in the press release, it was down 11.2% versus 2019. Do you think that's all COVID related or is there something else happening sufficiently? Thanks.

[Bill Rutherford, CFO at HCA Healthcare]

All right, Ann. Thank you. Let me start with the payer mix. Our payer mix, I think as Sam alluded to in his comments, remains favorable, with our managed care and others growing probably 12%-15% over the prior year. Our Medicare showed growth, not quite at that level. We were 2%-3% on Medicare. Whether we look at it 2019, very similar trends. We continue to expect favorable payer mix trends going forward.

[Sam Hazen, CEO at HCA Healthcare]

With respect to labor, or not labor, surgery in the third quarter, as I mentioned in my comments, we constrained surgery out of need for other patient care requirements. We used our surgical staff in many instances to support COVID patients across our facilities. Number one, we had to use physical space in our recovery rooms at times to take care of people.

[Sam Hazen, CEO at HCA Healthcare]

From that standpoint, we did reduce elective care during the quarter at many of our hospitals, and we reduced transfers in that typically result in surgeries of some sort in many instances. We do think that that volume will recover as it's recovered in previous periods where we had to do the same thing, second quarter to first quarter, as an example. We anticipate recovery in that. From that standpoint, we are working our way through reopening surgery capacity across the company in an appropriate fashion, and we really don't see any structural issues with our surgical activity across the company.

[Ann Hynes, Senior Healthcare Services Equity Analyst and Managing Director at Mizuho Securities]

Thank you. Thanks.

[Mark Kimbrough, VP of Investor Relations at HCA Healthcare]

Chris.

[Operator]

The next question is from Brian Tanquilut with Jefferies. Your line is open.

[Brian Tanquilut, Senior Analyst of Healthcare Services and Digital Health Equity Research at Jefferies]

Hey, good morning, and congrats to you guys on the quarter. I guess my question is, as it relates to guidance, it's sort of unusual for you to see a sequential decline in guidance in EBITDA from Q3 to Q4, which is what's implied in the midpoint of the 2020 guidance. Just wondering if that's just conservatism? As I think about the 2022 commentary, 2%-3% volume, how are you thinking just about the margin trend, with labor in the background? Should we expect that margin to translate to like a 2%-3% EBITDA growth rate as well?

[Bill Rutherford, CFO at HCA Healthcare]

All right, Brian. Yeah, Brian, let me start with the fourth quarter guidance. We think our range provides some level of growth. We recognize that the midpoint is under still a lot of variables at play. We continue to manage the company the best we can to continue to drive growth. We've had very few normal months to project from. Again, I think our range is appropriate at this level. It's roughly a $350 million raise at the midpoint compared to our previous guidance. Again, I think it's appropriate from how we read it right now.

[Sam Hazen, CEO at HCA Healthcare]

Margin, maybe that's also just margins.

[Bill Rutherford, CFO at HCA Healthcare]

Well, there's going to be a lot of variables that play into margins for next year. As we conclude our planning, we'll talk to you further about those. I think we have a history to continue to drive reasonable margins going forward, and that's our expectation to be able to continue to do that.

[Mark Kimbrough, VP of Investor Relations at HCA Healthcare]

All right, Brian. Thank you.

[Operator]

Our next question is from Justin Lake with Wolfe Research. Your line is open.

[Justin Lake, Analyst of Healthcare Services at Wolfe Research]

Thanks. A couple things here. Just one, wanted to clarify, given that historically, both either DRG growth or the company is in the mid-singles, when you say modest is a fair bit lower single digits there, kind of the drop-off point for 2022. My question's on labor. Can you give us a little color on 2 things? One, any kind of help on maybe the dollar amounts and the % of temporary labor, travel labor that you're running? Given some of the costs have been great on the revenue side, or I should say the cost side as well. Can you walk us through how your labor costs are run through the year in terms of maybe what percent of your labor against these price increases quarterly? I know it's not all just one. Thanks.

[Bill Rutherford, CFO at HCA Healthcare]

You snuck three questions in on one call, [audio distortion].

[Bill Rutherford, CFO at HCA Healthcare]

Hey, Justin Lake, this is Bill Rutherford. Let me start with kind of 2022. Our intention was to provide some broad commentary, not really ready to go into a lot of details. As we've mentioned throughout the course of the year, we know we've received some COVID support from the DRG add-on payments, HRSA payments for uninsured COVID payments, as well as the delay of sequestration cuts. These programs hit about $625 million year to date, that could reach close to $750 million-$800 million for the full year. We don't have a full line of sight now on what to expect for these programs going forward. We hope to have some clearer assessment of these as we complete the planning process, but for now, we're not really expecting those to continue to benefit going into 2022.

[Bill Rutherford, CFO at HCA Healthcare]

However, we also have some COVID-related costs this year that we don't expect to continue going forward. Supply-related costs, cost of screeners, and the like. Our broad thinking now is we should reasonably expect to be able to generate our historical growth rate of 5%-6% after netting out these amounts. That is what will result in some modest growth year-over-year on an as-reported basis. That was kind of our broad thinking right now. We'll firm that up as we go through our planning cycle. That was the intention of our commentary, to show that we still see some growth going forward in 2022.

[Sam Hazen, CEO at HCA Healthcare]

With respect to labor, again, we used whatever labor we could find to take care of record census that the company was experiencing with the Delta variant surge. We used contract labor, overtime, again, bonuses for our full-time staff, whatever it took to staff to the patient load that we had. That resulted in about 10%-12% of our, that obviously trends down naturally as we have a less COVID census. We've had that pattern in the fourth quarter of last year and the first quarter of this year, and we expect that pattern to continue. As it relates to the wage rates and the changes that we have, they vary across the company.

[Sam Hazen, CEO at HCA Healthcare]

Generally speaking, they're mostly in the second quarter and third quarter. That's part of the natural trend that we see inside of our labor costs as we move through the course of the year. One thing, Bill was alluding to this, typically we have fourth quarter seasonality that generates more activity in the fourth quarter than we have in the third quarter. We don't have a baseline third quarter to judge seasonality right now. That's part of the challenge that we've got. I think the company has proven that it can manage in a surge very effectively and produce really solid margins. In a reboot, like we did in the second quarter, manage through that transition in a very effective way.

[Sam Hazen, CEO at HCA Healthcare]

I fully anticipate that our teams will be able to navigate through the back part of the third quarter into the fourth quarter and on into next year in hopefully a reboot mode in a way that ultimately produces success for the company.

[Mark Kimbrough, VP of Investor Relations at HCA Healthcare]

Justin, thank you for the question.

[Operator]

The next question is from Scott Fidel with Stephens. Your line is open.

[Scott Fidel, Managing Director and Senior Research Analyst of Healthcare Services at Stephens]

Hi, thanks. Good morning. I was curious if you could talk a bit about what you see in the Medicaid volumes. Just been interested too, it seems like Medicaid volumes have continued to trend relatively low in terms of the overall mix, even though Medicaid enrollments are just up so much because of the extension of the recent [determination]. Just interested in your perspective on what you're thinking around that aspect in terms of the lower Medicaid volumes relative to the increases in Medicaid enrollment growth.

[Mark Kimbrough, VP of Investor Relations at HCA Healthcare]

Great. Thanks, Scott.

[Bill Rutherford, CFO at HCA Healthcare]

Yeah, Scott, I'll try. We did see Medicaid growth when I look at 2021 versus 2020 of almost 9%. I don't have at my fingertips what Medicaid enrollment has done in our states. I don't have that as a relative base. We have seen Medicaid growth in this quarter, at least year to date. We're tracking at about 7%, perhaps that does track with enrollment going forward as well.

[Mark Kimbrough, VP of Investor Relations at HCA Healthcare]

Thanks, Scott.

[Operator]

The next question is from Ralph Giacobbe. Your line is open.

[Ralph Giacobbe, Analyst at Citigroup]

Hello, can you hear me?

[Sam Hazen, CEO at HCA Healthcare]

Yeah. Hey, Ralph.

[Ralph Giacobbe, Analyst at Citigroup]

Hey. Good morning.

[Ralph Giacobbe, Analyst at Citigroup]

Thanks. Appreciate it. I guess first, and I know you want to sort of hold off on guidance, but you gave us a volume of 2%-3%, hoping you'd give some sense on how you see the specialty path developing next year. Then specifically just on the acuity mix. Obviously another strong quarter there. Is there any way to exclude COVID out and give us a sense of what that is, either year-over-year or relative to 2019. Thanks.

[Mark Kimbrough, VP of Investor Relations at HCA Healthcare]

Hey, Ralph. Thanks.

[Sam Hazen, CEO at HCA Healthcare]

Well, as I said, this is Sam. We do anticipate that acuity levels will be strong as we move forward into 2022. Our non-COVID acuity levels for the year have been up compared to 2019, and so we have seen a natural lift in acuity. Part of that is strategic, part of that is some migration into outpatient, and part of that is just the environment that we're in, we believe. We anticipate that acuity levels will remain strong. I don't know that we've assigned a metric to it at this particular point in time. If you look at our non-COVID activity for the year as a whole, it is up compared to 2019. We anticipate that at this particular juncture, continuing into 2022.

[Mark Kimbrough, VP of Investor Relations at HCA Healthcare]

All right. Thank you, Ralph.

[Operator]

Our next question is from Frank Morgan with RBC Capital Markets. Your line is open.

[Frank Morgan, Managing Director and Healthcare Services Equity Research at RBC Capital Markets]

Good morning. Just curious on the surgery side, any additional color you could provide to us on a regional basis between in and outpatient and freestanding surgical volumes, and where you saw the biggest impact for COVID? Thanks.

[Sam Hazen, CEO at HCA Healthcare]

Our inpatient surgeries were the only metric, again, as I mentioned in my comments, that were down for the quarter, and that's because we used a lot of the space that was necessary for COVID patients. Our outpatient activity was up. It was up 7%. It was up more in our freestanding ASCs than it was in our hospitals, but both were up. When you look at it against 2019, I think, again, we had growth, with the exception of inpatient surgery, Frank. That again, is a direct correlation to the fact that we needed that space for COVID inpatients in order to manage our capacity from both staffing and a beds standpoint.

[Frank Morgan, Managing Director and Healthcare Services Equity Research at RBC Capital Markets]

Got you. Just from a geographic standpoint, on the outpatient side, did you notice any more of an effect in, say, the Texas and Florida markets, say, in outpatient because of COVID? Thanks.

[Sam Hazen, CEO at HCA Healthcare]

I don't have all of it in front of me. Obviously, Florida and Texas were very intense geographies for us with the Delta variant, it's reasonable to assume that that's where we had more pressure in those markets than we did in other parts of the country. That would be my reaction to that question, Frank.

[Mark Kimbrough, VP of Investor Relations at HCA Healthcare]

All right. Frank, thank you so much.

[Frank Morgan, Managing Director and Healthcare Services Equity Research at RBC Capital Markets]

Thank you.

[Operator]

Our next question is from Pito Chickering with Deutsche Bank. Your line is open.

[Pito Chickering, Healthcare Facilities and Medical Devices Analyst at Deutsche Bank]

Hey, good morning, guys. Thanks for taking my questions. For your 2022 revenue commentary, you talked about the high procedures continuing. Just curious, what is fueling that? What areas are driving that? Is it cardio recovering more, orthopedics, et cetera? Then as I think about 2022 beyond, just a question for you, Sam. Once you get over the noise from COVID, does the long-term growth that you've laid out in the past, does it continue from these levels once you get through the noise that you see in 2022? Thanks so much.

[Mark Kimbrough, VP of Investor Relations at HCA Healthcare]

All right. Thanks, Pito.

[Sam Hazen, CEO at HCA Healthcare]

Our belief is that demand for healthcare services is still strong. We think it's going to be 1.5%-2% when you look out into the intermediate run, and so forth. We think for HCA, we have a differentiated portfolio of markets, and we have strong economies underneath that differentiated portfolio where population growth, job growth, and so forth is existent. Then we've had this pattern, and we think this pattern can continue of market share gains. As we look at where we are today versus where we were heading into 2020, we think we've improved our overall positioning competitively with broader networks, more physicians, better clinical outcomes, and so forth. We will continue to resource our model, and we think that model still has growth embedded in it because of these factors.

[Sam Hazen, CEO at HCA Healthcare]

We're not ready to give any particular guidance as it relates to out years, but we do think the company's approach can still yield successful returns for our shareholders.

[Pito Chickering, Healthcare Facilities and Medical Devices Analyst at Deutsche Bank]

All right. Thank you.

[Operator]

Next question is from Glenn Mateo with SVB Leerink. Your line is open.

[Whit Mayo, Senior Research Analyst at SVB Leerink]

Okay, thanks. As I reflect back on commentary a year ago, Sam, you referenced a lot of, I guess we'll call it emerging opportunities. I think the ability to align closer to certain medical groups comes to mind. It might just be helpful to hear how some of these opportunities have evolved over the last 18 months, and maybe I mean this in the context of market share shifts, et cetera, but just any high level observations or thoughts would be helpful. Thanks.

[Mark Kimbrough, VP of Investor Relations at HCA Healthcare]

All right. Thank you, Glenn.

[Sam Hazen, CEO at HCA Healthcare]

Well, let me start with the fact that our most recent market share data that we have, which is late last year, 2020 or first part of this year, I don't remember the exact period, shows us at a high water mark. We picked up market share in 2020 when I look at just what happened in that year. I'll start with that. Additionally, we have added to our networks. We have added, in some cases, a few hospitals here and there, whether it's new hospitals that have opened or we've had small acquisitions of hospitals to round out our network offering. In particular, on the outpatient side, we've added a reasonable number of new facilities, whether it's new urgent care center platforms, new freestanding emergency rooms, some ambulatory surgery.

[Sam Hazen, CEO at HCA Healthcare]

Then we’ve added to our physician platform over the last 18 months, some of which has been development of existing practices in our communities, but also new practice acquisitions that have added to our offerings. I think our outpatient facility capability is up to about 2,200 outpatient facilities. At the end of 2019, it was just a little north of 2,000. We continue to add capabilities and convenience for our patients, again, creating a broader network offering in these communities. We have done some acquisitions. The pipeline as it relates to outpatient acquisitions is strong. Our development pipeline of new outpatient facilities is robust, and we fueled that with investment.

[Sam Hazen, CEO at HCA Healthcare]

Then as Bill indicates, we have a strong pipeline of projects that will come online in 2022 and 2023 that are connected to both our hospital platform as well as our outpatient platform. We see, again, the model, the flywheel, if you will, of HCA continuing to produce solid results and deliver value to our patients and value to our shareholders.

[Mark Kimbrough, VP of Investor Relations at HCA Healthcare]

Thank you, Chris.

[Operator]

The next question is from Lance Wilkes of Bernstein. Your line is open.

[Lance Wilkes, Managing Director at Bernstein]

Yeah. I just wanted to follow up on the capital deployment theme. If you could talk a little bit about what you're looking at as far as enterprise assets instead of top the local markets. In particular, earlier in the year, you were talking about the flywheel concept and looking at digital or virtual assets or other sorts of assets that might feed into it. Just interesting if you've had any evolution in thought as to what you're going to be focused on there, and then if there's any progress reports on that. Thanks.

[Sam Hazen, CEO at HCA Healthcare]

All right. Thanks, Lance. We do see complementary opportunities to use digital capabilities more effectively in our company. As I've mentioned on previous calls, advancing technology in our organization is a tremendous opportunity to improve care, support our physicians and nurses with decision-making capabilities, as well as a more safe environment. We also see with that more consistency and transparency, which we believe can produce more efficiencies as we go through it. We've got a number of initiatives that are connected to that. In addition to that component, we are using telemedicine to support outreach to our patient population and meet them where they want to be.

[Sam Hazen, CEO at HCA Healthcare]

Then we see opportunities for telemedicine to support what goes on inside of our facilities and preserve better care for our patients by helping our physicians and our nurses with really extended capabilities that can come from telemedicine inside the walls of our hospitals. Those areas are progressing. They're showing early signs of value in some instances. Then when they connect with our care transformation agenda, which is being led by one of our physicians and his team, we're very excited about what that potentially yields in the form of better care, more efficient care, and so forth. We have a number of initiatives underway. They're not completely implemented across the company because we're still studying what are the best approaches, but we're pretty excited about what this agenda can do for our organization.

[Mark Kimbrough, VP of Investor Relations at HCA Healthcare]

All right. Thanks, Lance.

[Operator]

The next question is from Jamie Perse with Goldman Sachs. Your line is open.

[Jamie Perse, Equity Research Associate of Medical Technology at Goldman Sachs]

Hey, good morning, guys. Thanks for the question. Early in the pandemic, you outlined a couple different stages of cost opportunities that you were thinking about. How are those tracking and how much more of the paid costs can you optimize? Are those enough to offset some of the incremental wage pressures you're seeing and other inflationary pressures out there?

[Bill Rutherford, CFO at HCA Healthcare]

This is Bill. Thanks for the question. As we have talked about before, we have resiliency efforts underway. We started last year. Those efforts continue. We have some of those efforts that are implemented and we're realizing the benefits now, and we have some of those efforts that are still in the early stages of implementation that will provide benefit going to the future. We do expect some of those areas to help offset some of the inflationary increases we might see. These efforts are centered around utilizing our scale, where we have the ability to consolidate and standardize functions that may be distributed right now. They're also looking at some structural changes in terms of how we support our field-based operations. We have a number of efforts underway.

[Bill Rutherford, CFO at HCA Healthcare]

Some of them are at the completion stage and the benefits are being realized as we speak, and some of them still are in the early stages that will provide benefit going forward. It's an important part of our activity level right now. We have teams focused on a variety of efforts, and we have a certain governance structure in place to make sure that they get executed timely. They will continue going forward.

[Mark Kimbrough, VP of Investor Relations at HCA Healthcare]

All right. Thank you, Jamie Perse.

[Jamie Perse, Equity Research Associate of Medical Technology at Goldman Sachs]

All right. Thank you.

[Operator]

The next question is from A.J. Rice with Credit Suisse. Your line is open.

[A.J. Rice, Managing Director of Equity Research at Credit Suisse]

Thanks. Hi, everybody. Mark, I don't know if we're going to have you on the fourth quarter call, so I just would say congratulations on your retirement and best wishes. I want to ask about the capital deployment a little further. Obviously, this year you did $6 billion. You've done $6 billion in share repurchases. When you think about capital deployment going forward, what kind of pace do you think is reasonable for that? I know you've already announced the Salt Lake City deal. On the side of coming out of the pandemic, hospital assets or other more significant assets that might be available, can you talk about that pipeline? Specifically with Salt Lake, when you made your comments, Bill, about next year's growth, I'm assuming until that deal closes, you're not incorporating that in your commentary.

[A.J. Rice, Managing Director of Equity Research at Credit Suisse]

My understanding is it's what, $90 million-$100 million of EBITDA?

[Bill Rutherford, CFO at HCA Healthcare]

Yeah. A.J., you are correct. We are not incorporating anything into that, into our commentary at this point in time. To the capital allocation, let me step back and talk a little broadly about that. As I mentioned in my comments, we are in a very strong position as we approach our capital allocation decisions for next year, given our cash flow generation, the balance sheet position, and the liquidity we're carrying. As we've described it in the past, we're really focused on what I describe as a balanced approach to capital. Our first priority is evaluating opportunities to deploy capital in our markets to capture growth through our internal capital program. We haven't finalized on that range yet, but I would anticipate we'll increase it commensurate with the opportunity.

[Bill Rutherford, CFO at HCA Healthcare]

As we mentioned in our guidance, it should be somewhere around $3.7 billion this year, maybe a little below that. Prior to the pandemic, we were at $4 billion-$4.2 billion. We're evaluating where that should settle for next year. We think that will be an important part of the continuing for growth. After that, it's a matter of how best to utilize our free cash flow to drive value. The dividend program and share repurchase program, we expect to continue to be an important part of our overall capital allocation process. We haven't finalized that, but we have ample capital capacity to give any consideration to both of those programs. I would expect them to be part of our balanced portfolio of capital going forward.

[Mark Kimbrough, VP of Investor Relations at HCA Healthcare]

All right. Thank you, A.J.

[Operator]

The next question is from John Ransom with Raymond James. Your line is open.

[John Ransom, Managing Director of Healthcare Equity Research at Raymond James]

Hey. Good morning. I'd add my best wishes to Mark Kimbrough.

[Bill Rutherford, CFO at HCA Healthcare]

He's not leaving yet. We still got him for a little while.

[Mark Kimbrough, VP of Investor Relations at HCA Healthcare]

I'll be here for the duration.

[John Ransom, Managing Director of Healthcare Equity Research at Raymond James]

I suggest.

[Bill Rutherford, CFO at HCA Healthcare]

Yeah, I get the big nine.

[John Ransom, Managing Director of Healthcare Equity Research at Raymond James]

I'm thinking of polka dancing or ballroom dancing, something that can ease him back up after his hobby.

[Bill Rutherford, CFO at HCA Healthcare]

That's right.

[John Ransom, Managing Director of Healthcare Equity Research at Raymond James]

Just thinking about fourth quarter in conjunction with your guidance. I mean, your labor costs, you talked about it a lot, but they jumped up about 11%, after kind of hanging in the $640 million range for three quarters. If we think about the fourth quarter, let's say COVID drops by 5%, 6%, some of that pressure comes off. Isn't it reasonable to think that the labor costs get a little bit of a breather sequentially, just relative to less acute pressure from what we saw as a Delta wave peak in late August?

[Bill Rutherford, CFO at HCA Healthcare]

Yeah, John, this is Bill. I think you're saying much in as earlier commentary. This quarter was affected by having and gaining the labor any way we could to support the volume we were seeing. As COVID does subside, we expect those premium programs that we implemented during the quarter to subside. Whether it be utilization of the contract labor, looking at the overtime as well as some of these bonus shift differentials that we have to pay. We do expect that to come down relative to where we had in third quarter. I understand there's still first quarter.

[John Ransom, Managing Director of Healthcare Equity Research at Raymond James]

Just as a follow-up. If you're talking about less potential revenue and less acute pressure from labor, wouldn't that imply EBITDA going up sequentially, not sequentially?

[Bill Rutherford, CFO at HCA Healthcare]

Yeah, I understand that question. As we said before, historically we see some seasonality. We don't know what the seasonality change will be. We think our range provides the opportunity for us to grow at the top end of that. Again, I think just given the environment we're seeing, we're prudent.

[John Ransom, Managing Director of Healthcare Equity Research at Raymond James]

Okay. Thank you.

[Mark Kimbrough, VP of Investor Relations at HCA Healthcare]

All right, John. Thanks so much.

[Operator]

The next question is from Josh Raskin with Nephron Research. Your line is open.

[Josh Raskin, Analyst at Nephron Research]

Thanks. Good morning. I'm going to hold my comments on Mark, I guess, for another 90 days to give Adam support too. My question's on value-based care. From the perspective of HCA as the largest hospital operator in the country, one of the largest employers of physicians in the country. Do you like this movement? It doesn't feel like it's being felt much at the facility level. Do you think there are opportunities for HCA on the hospital side to benefit from value-based care contracts? How do you think about opportunities for your physician base? Because I know there's a ton of conversation around enabling providers at this point.

[Sam Hazen, CEO at HCA Healthcare]

We have certain aspects of value-based care embedded in, obviously, Medicare reimbursement. In some of our commercial contracts, we have aspects of value-based care components as part of our reimbursement methodologies. That will continue, I think, into the future. Is it accelerating in our facility structures? No. Inside of our physician platform, we do see opportunities to continue to push further into value-based care. Again, in that particular platform in our company, we have aspects of value-based care. They vary a little bit from one market to the other, depending on the circumstances and the demographics and payer dynamics in those markets.

[Sam Hazen, CEO at HCA Healthcare]

We do see it growing more in the physician platform than on the facility side, I would submit. I think if you pull up and you look at our relationships across the organization in the payer environment, they're very strong. We're 85% contracted for 2022. We're about 50% contracted for 2023 on terms that work for both organizations. They continue a lot of the structure that's already in place. We evolve as we renew with what's going on in the marketplace. We are in most commercial contracts in just about every market where we do business and in most Medicare Advantage relationships as well.

[Sam Hazen, CEO at HCA Healthcare]

That's a key part of our approach, that's why it's important for our model within each of the markets to be comprehensive, both in outpatient offerings, convenient for the patients, and then having different price points for the payers, but ultimately creating a full system that can offer solutions, and we adjust those solutions to fit the situation with each payer. Some of that, again, can be value-based. Some of it can be different approaches to other reimbursement terms. We think we're striking the right balance in how we approach that.

[Mark Kimbrough, VP of Investor Relations at HCA Healthcare]

Josh, thanks.

[Operator]

Next question is from Gary Taylor with Cowen. Your line is open.

[Gary Taylor, Managing Director of Equity Research at Cowen]

Hey, good morning, guys. Congrats on the quarter. I know it was a pretty difficult one to manage through, and the street is immediately looking for the next data point. Maybe not enough credit given when it's due. Good job on the quarter. I wanted to ask, I think this primarily goes to Bill. When we looked at where your margins were trending a few years pre-pandemic, up 200 basis points. I think your guidance for next year inherently assumes margins come back to some degree. We understand all the factors that have been driving it, the higher occupancies, better mix, the higher acuity, despite the COVID costs, despite the labor costs, et cetera.

[Gary Taylor, Managing Director of Equity Research at Cowen]

Bill, I feel like one year or so ago, you talked about some opportunities to take some real sort of permanent efficiencies out of the cost structure. Just wanted to get your thoughts now as we sort of head into 2022 and beyond. Should investors think that margins ultimately just go right back to the low 19%? Are there good reasons structurally to think that maybe you can sustain somewhere in the middle?

[Bill Rutherford, CFO at HCA Healthcare]

Gary, one, thanks. It is a very good question. Assure we are focused on driving as much efficiency as we can throughout the organization. I think we have a pretty good track record of doing that. You're right. If you go pre-pandemic, we were hovering 19% margins or a couple quarters would be 20%. We've changed that. Some of that is due to the mix in acuity on there. Our focus will be to continue to drive margins. We have been supported by a couple of those COVID Support Programs that I spoke about.

[Bill Rutherford, CFO at HCA Healthcare]

We fully anticipate once we account for those, that we should maintain and find some incremental growth to margins going forward. All of our efforts, including our resiliency plans and our day-to-day management, is to continue to drive efficiencies, utilize the scale of the organization to bring benefits. I do believe that once we get into a normalized kind of post-COVID surge environment and we compare our current margins to where they were pre-pandemic, you'll see some elevation in that.

[Mark Kimbrough, VP of Investor Relations at HCA Healthcare]

Thank you, Gary.

[Sam Hazen, CEO at HCA Healthcare]

When you look at the Gary Taylor, this is Sam Hazen. When you look at the third quarter of 2019, we declared almost what I call 36% EBITDA clearance. In other words, our margins in 2021 against 2019 were 2x what the average margin was in 2019. Obviously, it's significant compared to that same period then. We do see some structural pieces that Bill Rutherford was alluding to, but obviously there's a potential of inflation that we have to figure out exactly what the implications of that are, and we think some of our strategies will mitigate it. We have been able to reposition the profitability of the company, and we're pushing to try to sustain those gains as much as we possibly can.

[Mark Kimbrough, VP of Investor Relations at HCA Healthcare]

Thank you, Gary.

[Operator]

The next question is from Andrew Mok with UBS. Your line is open.

[Andrew Mok, Analyst at UBS]

Hi, good morning. First, one clarification, then I'll get to my question. Bill, earlier, I think you said 5%-6% core EBITDA growth off of the earnings base, ex government aid. If so, it sounds like you actually expect accelerating growth in 2022 compared to the long-term growth target of 4%-6%. Is that fair?

[Bill Rutherford, CFO at HCA Healthcare]

We've had long-term 4%-6%. I think if you look at our actual historical, we'd be more in that 5-6. Again, we're in early stages, and the intent was to give you some broad commentary versus specifics on there. That was how the commentary was structured.

[Andrew Mok, Analyst at UBS]

Got it. Just a follow-up on the de novo deployment. I think you have at least 20 to 30 de novos underway between ambulatory surgery and inpatient rehab. Can you give us a sense for the cadence of when those facilities come online and the expected profit ramps of those facilities over the next 18 months?

[Sam Hazen, CEO at HCA Healthcare]

We have a pipeline of urgent care that I know is coming online in 2022 or 2023, again, through acquisition or de novo development. We have maybe 10 or 12 ambulatory surgery centers, some of which come online in the fourth quarter. Most come online in 2022 of that particular component. Then we have some other outpatient facilities that maybe 15 or so in those categories come online in 2022 with another 15 or so in 2023. We have a lot in different categories coming online, that's part of the continued addition to our 2,200 outpatient facilities. I don't have the earnings expectations around those or a composite on each, all of them in total. We do have a pretty active development. Those are complementary, and there's a national ramp in them as well.

[Sam Hazen, CEO at HCA Healthcare]

For the most part, we're really bullish on the prospects for those outpatient facilities.

[Andrew Mok, Analyst at UBS]

Thank you.

[Mark Kimbrough, VP of Investor Relations at HCA Healthcare]

Thank you, Andrew.

[Operator]

There are no further questions at this time. I'll turn the call over to Mr. Kimbrough for any closing remarks.

[Mark Kimbrough, VP of Investor Relations at HCA Healthcare]

Chris, thank you so much for your help today. Thanks, everyone, for joining our call. Hope you have a wonderful weekend. I'm around this afternoon, and I can answer any additional questions you might have. Take care.

[Operator]

Ladies and gentlemen, this concludes today's conference call. Thank you for participating. You may now disconnect.

Participants

Executives

• Bill Rutherford, CFO
• Mark Kimbrough, VP of Investor Relations
• Sam Hazen, CEO

Analysts

• A.J. Rice, Managing Director of Equity Research at Credit Suisse
• Andrew Mok, Analyst at UBS
• Ann Hynes, Senior Healthcare Services Equity Analyst and Managing Director at Mizuho Securities
• Brian Tanquilut, Senior Analyst of Healthcare Services and Digital Health Equity Research at Jefferies
• Frank Morgan, Managing Director and Healthcare Services Equity Research at RBC Capital Markets
• Gary Taylor, Managing Director of Equity Research at Cowen
• Jamie Perse, Equity Research Associate of Medical Technology at Goldman Sachs
• John Ransom, Managing Director of Healthcare Equity Research at Raymond James
• Josh Raskin, Analyst at Nephron Research
• Justin Lake, Analyst of Healthcare Services at Wolfe Research
• Kevin Fischbeck, Senior Research Analyst at BofA Securities
• Lance Wilkes, Managing Director at Bernstein
• Pito Chickering, Healthcare Facilities and Medical Devices Analyst at Deutsche Bank
• Ralph Giacobbe, Analyst at Citigroup
• Scott Fidel, Managing Director and Senior Research Analyst of Healthcare Services at Stephens
• Whit Mayo, Senior Research Analyst at SVB Leerink