Community Health Systems Q1 2024 Earnings Call Transcript

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Provided by Quartr
April 25, 2024

Key Takeaways

  • Q1 2024 financial performance: Same-store net revenue increased 5.7%, admissions rose 3.8%, adjusted EBITDA reached $378 million (up 12.8%) and margins expanded 120 bps, in line with guidance.
  • Insourced program management: 29 ED and hospitalist programs plus 2 anesthesia sites are now self-operated, yielding better quality metrics, improved throughput, lower premium-pay usage and higher patient satisfaction.
  • Capital investments: Opened a new tower in Knoxville, Tenn., and on track to finish Baldwin County, Ala. expansion by year-end, while launching two new ASCs in Tucson, Ariz. and Cedar Park, Texas to boost outpatient capacity.
  • Drug cost partnership: Became the first health system to buy injectable epinephrine and norepinephrine from Mark Cuban Cost Plus Drug Co’s new plant, aiming to lower drug costs, avoid shortages and improve medication safety.
  • Asset divestiture and liquidity: Agreed to sell Tenova Cleveland for ~$160 million (about 10× EBITDA with upside), pursuing over $1 billion in portfolio sales to strengthen liquidity (net debt/EBITDA 7.7×; $618 million ABL capacity).
AI Generated. May Contain Errors.
Earnings Conference Call
Community Health Systems Q1 2024
00:00 / 00:00

There are 11 speakers on the call.

Operator

Good day, and welcome to the Community Health Systems First Quarter 20 24 Earnings Conference Call. All participants will be in a listen only mode. After today's presentation, there will be an opportunity to ask questions. Please note this event is being recorded. Would now like to turn the conference over to Mr.

Operator

Anton Hai, Vice President of Investor Relations. Please go ahead, sir.

Speaker 1

Thank you, Chuck. Good morning, everyone, and welcome to Community Health Systems' Q1 2024 Conference Call. Joining me on today's call are Tim Hinchen, Chief Executive Officer Kevin Hammonds, President and Chief Financial Officer and Doctor. Lynn Simon, President, Healthcare Innovation and Chief Medical Officer. Before we begin, I must remind everyone that this conference call may contain certain forward looking statements, including all statements that do not relate solely to historical or current facts.

Speaker 1

These forward looking statements are subject to a number of known and unknown risks, which are described in headings such as Risk Factors in our annual report on Form 10 ks and other reports filed with or furnished to the SEC. Actual results may differ significantly from those expressed in any forward looking statements in today's discussion. We do not intend to update any of these forward looking statements. Yesterday afternoon, we issued a press release with our financial statements and definitions and calculations of adjusted EBITDA and adjusted EPS. We've also posted a supplemental slide presentation on our website.

Speaker 1

All calculations we will discuss exclude impairment expense as well as gains or losses on the sale of businesses, expense from government and other legal matters and related costs, expense from business transformation costs and expenses related to employee termination benefits and other restructuring charges. With that said, I'll turn the call over to Tim Hynchon, Chief Executive Officer.

Speaker 2

Thanks, Anton. Good morning and thank you for joining our Q1 conference call. CHF 2024 is off to a good start with the solid operating and financial results achieved in the Q1. Same store net revenue increased 5.7 percent compared to the Q1 of 2023. Same store admissions increased 3 0.8% and adjusted admissions were up 1.9%.

Speaker 2

The prior year comp was our most challenging of the year with strong same store admissions growth of 4.8% and adjusted admissions of 9.4%. So we were very pleased to see continued strong demand. Same store ED visits increased 3.4% in the quarter and surgery slightly increased. In the 1st quarters of both 2023 and 2024, surgical volume was well above the Q1 of 2019, beating our pre COVID baseline by approximately 10%. Growth coupled with strong expense management led to 120 basis points of margin expansion year over year.

Speaker 2

Adjusted EBITDA came in at $378,000,000

Speaker 3

up 12.8%

Speaker 2

from the prior period on a consolidated basis, with growth in our core portfolio outpacing the impact of prior period divestitures. This first quarter performance puts us very much in line with the guidance provided in February, but our work is not yet done and our leaders remain focused on the opportunities ahead of us. We continue to make steady progress in each of our near term priorities and we are especially pleased with investments that are accelerating growth. We opened our new tower in Knoxville, Tennessee a few weeks ago and our Baldwin County Alabama campus expansion remains on schedule to open by the end of the year to address the strong demand for healthcare services in that fast growing market. Investments continue into incremental access points to expand outpatient capacity in multiple markets, which included the opening of 2 new ASCs during the quarter in our Tucson, Arizona and Cedar Park, Texas markets.

Speaker 2

Another high impact initiative that we've been updating you on is our work to in source the management of certain hospital based medical specialties. In a minute, Kevin will share details about how the financial impact from this initiative is tracking to our expectations, but I want to address the clinical and operational improvements we are seeing. We now manage 29 EB and Hospitals programs and across the board, we are realizing better quality metrics, improved throughput, lower premium pay utilization and greater patient satisfaction. These improvements are consistent with our enterprise goals and it is gratifying to see so much progress, especially when you consider that we have been self operating these programs for less than a year. We've expanded our efforts to in source select anesthesia programs with 2 sites already in place and additional opportunities expected to come online in the months ahead.

Speaker 2

We don't often take the opportunity to share our internal programs that are driving alignment across the organization. But today, I want to mention that we recently hosted our 2024 Health System CEO and Medical Staff Leadership Conferences. We spent time reviewing our goals and the initiatives that will drive results over the next few years. It was energizing to see so much commitment from our local health system leaders who are absolutely focused on executing our strategies and leveraging the resources and support available across the CEHS organization. I remain excited about the opportunities ahead this year and into the future.

Speaker 2

During the conferences, we also discussed our enthusiasm to be on the leading edge of innovation, leveraging our size and scale to discover new opportunities and to improve care design delivery and outcomes, utilizing technology and joint venture partners that are focused on moving healthcare forward. Last quarter, Doctor. Miguel Vinay talked about our partnership with Google Cloud and worked to unify our data into a single platform that can enable the future use of AI in healthcare settings. This quarter, I've asked Doctor. Lynn Simon, President of Healthcare Innovation and our CMO to share more about innovation across CHS and in particular our new partnership with Mark Cuban Cost Plus Drug Company.

Speaker 2

Lynn?

Speaker 3

Thanks, Tim. Over the past several quarters, we have implemented a number of innovative programs at CHF, including remote monitoring for people with chronic conditions, virtual support for people living with depression, anxiety and other behavioral health issues, an AI informed early warning system that alerts caregivers to potentially concerning trends during childbirth, and a virtual tech enabled there are opportunities to rethink and even disrupt the way we purchase products and services. As an example, our relationship with Mark Cuban, Cost Plus Drug Company has the potential to generate significant advantages for our affiliated hospitals by addressing rising drug costs and drug shortages. We recently became the 1st health care system to purchase injectable drugs produced in the new Cost Plus Drugs manufacturing plant in Dallas. Specifically, we purchased epinephrine, a life saving drug on the FDA's list of current drug shortages and norepinephrine for our hospitals in Texas and Pennsylvania.

Speaker 3

Through this strategic partnership, CHS will be advising and collaborating with Mark Cuban Cost Plus Drugs about additional ways we can address pharmaceutical costs, avoid drug shortages, reduce waste and improve medication administration safety and patient care. We expect this work to benefit not only CHS, but also other forward looking healthcare organizations. Tim?

Speaker 2

Thanks, Lynn. Before I turn the call over to Kevin, I'd like to recognize CHS Hospitals and Providers for a proud accomplishment. A recent report from the company Reputation, a global online reputation management firm that specializes in industries such as healthcare, financial services, hospitality and property management recognized CHF as number 1 among the 50 largest healthcare systems for online reputation and this is the 3rd year in a row we've ranked number 1. In 2023, cumulative average 4.5 star rating on review sites such as Google and our providers earned 4.8 stars. This speaks to our commitment to safety, quality and patient experience.

Speaker 2

We appreciate the confidence of our patients and thank our local health systems for all they do to make health care accessible, compassionate and worthy of this very positive feedback. Now I'll turn the call over to Kevin to review financial results. Kevin?

Speaker 4

Thank you, Tim, and good morning, everyone. As Tim indicated, we were pleased with financial results delivered in the Q1, which put us on track to achieve the guidance for 2024 that we provided in February. We are also pleased to see the momentum in volume growth that began last year continued into the Q1 of 2024 with 3.8% growth in admissions, 1.9% growth in adjusted admissions and 0.4 percent growth in surgeries, stepping over a particularly difficult comp from prior year. Net operating revenues for the quarter were $3,140,000,000 representing consolidated year over year growth of 1%. On a same store basis, net revenues were up 5.7%, driven by 1.9% growth in adjusted admissions and a 3.7% increase in net revenue per adjusted admission, which was positively impacted by improved rates, incremental state Medicaid reimbursement and strong inpatient growth.

Speaker 4

Although volume improvements continue to be led by increases in Medicare Advantage business, we did see a slightly more balanced growth profile in the Q1 of 2024 with improvements in commercial business as well. Adjusted EBITDA for the Q1 was 370 $8,000,000 compared with $335,000,000 in the prior year period $386,000,000 in the Q4 of 2023. Considering the sequential effect from the Brevera divestiture that closed late last year and lower recognition of Mississippi Medicaid expanded funding in the Q1 compared to the 4th quarter, we view our production of nearly flat sequential EBITDA as a sign of progress. Margin for the quarter was 12%, a modest decline sequentially despite the typical seasonal headwinds that affect 1st quarter performance, such as higher unemployment taxes and annual resets of co pays and deductibles in our commercial book. On a year over year basis, margin improved 120 basis points.

Speaker 4

We believe this is a strong start relative to our guidance for mid-twelve percent adjusted EBITDA margin for 2024. And we expect further margin expansion through strong cost controls, continued volume growth and top line leverage. We were again pleased with our performance on labor costs in the quarter. The average hourly wage rate approximately 3% year over year. Recall, we are anticipating an approximate 4% average hourly inflation rate for the full year 2024.

Speaker 4

Our progress in contract labor continued in the Q1 with contract labor spend of approximately $48,000,000 compared to $52,000,000 in the 4th quarter and approximately $85,000,000 in the Q1 of 2023. This performance was consistent with expectations and primarily reflects reduced utilization of contract nursing as a result of our retention and recruitment efforts as well as a lower hourly contract labor rate. We were also pleased to see continued progress from our in sourcing and other initiatives to address medical specialist needs that have surged over the past 2 years. Medical specialist fees were flat compared to the Q1 of 2023 and slightly down from the Q4. As Tim noted, we have seen strong operational improvements in the 29 ED and Hospice programs that we have brought in house since last fall and 2 anesthesia programs brought in house thus far.

Speaker 4

We believe we can continue to scale up these in sourcing efforts and are well positioned to keep further increases under control despite ongoing pressure, including those in anesthesia. Cash flows from operations were 96 $1,000,000 for the Q1 of 2024 compared with $5,000,000 in the year ago period. This improvement was primarily the result of improved earnings as well as the timing of collections from the buildup of certain accounts receivables at year end, which resulted in the overall net decrease in accounts receivable of approximately $39,000,000 from December 31, 2023. Capital expenditures for the quarter were $93,000,000 on track for our 20 24 guidance range $350,000,000 to $400,000,000 provided in February. As announced last week, we signed an agreement to divest Tenova Cleveland, located in Cleveland, Tennessee for approximately $160,000,000 plus the potential for an additional contingent consideration payment.

Speaker 4

And we continue to evaluate opportunities for further divestitures across a handful of markets that could total more than $1,000,000,000 in total proceeds. The divestiture of Tenova Cleveland is anticipated to close in the Q3, and we believe that 1 or more additional transactions could close within the calendar year, providing substantial capital for the company to redeploy. Net debt to trailing adjusted EBITDA was 7.7 times, slightly improved from 7.88 times at year end 2023. With $618,000,000 of borrowing capacity under the ABL, along with pending asset sale proceeds, we believe we have more than adequate liquidity to meet our needs going forward. Regarding Project Empower, we are continuing to make progress having now gone live with the 2nd wave of hospitals on April 1, without experiencing any disruption in care delivery.

Speaker 4

The progress we are making is right in line with our scheduled timeline and we believe we are already experiencing the benefits incorporating automation technologies to remove certain manual administrative tasks from our nurses' workflows and improved insight into our business

Speaker 5

at the sites that

Speaker 4

are live. We believe these benefits will translate into realized cost savings beginning later this year and into future periods. At this time, we'll turn the call back over to our operator for Q and A.

Operator

Thank you. We will now begin the question and answer session. Citi. Please go ahead.

Speaker 6

Great. Good morning. Thanks. I was just hoping you could dig a bit deeper on the cash generation in the quarter. Obviously, there's seasonality considerations.

Speaker 6

You talked about that AR release. Was there any impact from change in the cyber? I didn't hear that. And then, I guess, now that we're through the Q1, how would you expect cash generation to play out for the rest of the year just in context of your $500,000,000 to $650,000,000 embedded in guidance? Thanks.

Speaker 4

Thanks, Jason. So in typical or historical fashion, cash flow in the first quarter is typically our lowest cash flow quarter is a result of the reset of patient co pays and deductibles and more of your receivables being patient responsibility. We did have the benefit in Q1 of getting some additional cash flow in as a result of the accounts receivable that build up in the 4th quarter, including that from the Mississippi Supplemental Medicaid program that was collected in the Q1 of this year. In terms of other kind of working capital items, they were all pretty much in line with our expectations. We always have a little bit of a headwind in Q1 with the payment of our annual bonuses, which occurs just once a year.

Speaker 4

And then throughout the remainder of the year, as bonuses are accrued, that kind of turns itself around. Similarly, we'll have that situation in the second quarter as we fund our 401 plan just once annually. And therefore, that also has a negative impact on Q2 cash flows, but turns around throughout the remainder of the year as we build our accruals back up. In terms of our guidance on cash flow, at this point of the year, I think we're right in line and are comfortable with where we're guiding at.

Speaker 6

Okay, got it. Thanks. Maybe just as a follow-up, I wanted to ask on the Tennessee Hospital sale agreement. Can you give us a sense on what the revenue and EBITDA contribution of that asset is? And then what would the EBITDA multiple be implied if the Tennessee supplemental payment program is approved?

Speaker 6

It sounds like just I guess broadly I guess on divestitures, it sounds like you're keeping that potential for $1,000,000,000 in proceeds. Just if there's any other incremental color you can offer around your divestiture plans, how they're tracking and what you're seeing out there would be helpful. Thanks.

Speaker 4

Sure, Will. And let me follow-up to the second part of your first question as well related to change. We did not see any impact or nothing material as a result of any cash flow slowdown from change, healthcare's breach. We did not use them for billing and collection purposes. So that did not have an impact on us.

Speaker 4

Relating to the divestitures, the base price of the $160,000,000 is essentially a 10 times EBITDA multiple and trailing EBITDA for Cleveland. So then any contingent payment above that, we would anticipate putting the complete purchase price somewhere in the low teens multiple on a trailing basis. And then in terms of how Cleveland, their margin profile, they operate pretty similar to our kind of corporate average margins. So you can probably do the math in terms of getting a revenue contribution.

Operator

The next question will come from Brian Tanquilut with Jefferies. Please go ahead.

Speaker 7

Hey, good morning. Congrats on the quarter. Good morning. Hey, I guess my first question, there's a lot of discussion among investors on the monthly flow or monthly trend in volumes, obviously, with the calendar moves in Q1. Just curious what you can share with us in terms of what January, February, March looked like and how is that translating to April in terms of obviously we're on a more normalized calendar this quarter?

Speaker 4

Sure. So probably like most people, we saw pretty strong January February, some softness year over year in March. But I would really attribute that to how the calendar lined up with February having an additional business day this year with leap year. And then March's calendar had really 2 things going against it. 1, it had one fewer business day with just how the calendar lined up and then you also moved Good Friday and Easter holiday into March.

Speaker 4

It was in April of last year. So that has some impact not only from it being a holiday, but also around spring breaks in a number of markets that schools often schedule spring breaks around the holidays. So we think that that probably had some contribution to some of the volume trends that we saw in March. In terms of how we view that going forward, I think overall strong volume quarter for us and we see the momentum from that continuing on and don't believe that, that calendar the volatility monthly in the Q1 really influences much about how we're thinking about future quarters.

Speaker 7

Got it. Okay. And then maybe Kevin, just a quick cash flow question. The payout to the NCI during the quarter was probably higher than typical. So just curious what the moving pieces are there and how should we be thinking about NCI payments going forward?

Speaker 4

Yes. We're still comfortable with where we kind of guided for the full year, which is about $150,000,000 I believe on total NCI payments for the year. There was just some timing with some items accrued from the Q4 that carried forward into Q1 on NCI payments, but I would expect those to be on a more regular run rate beginning in Q2.

Speaker 7

Awesome. Sounds good. Thank you.

Speaker 4

Thank you.

Operator

The next question will come from Ben Hendricks with RBC. Please go ahead.

Speaker 8

Thank you very much. Good morning. It looks like SWB was a little favorable to our assumptions and perhaps to what you had guided to for the year. I was just wondering how you're thinking about the rest of the year and if any outperformance in the Q1 kind of pads the year expectations or if there's any reason to think that we might see some added inflation in later quarters? Thanks.

Speaker 4

Sure. So coming into the year, we anticipated about a 4% wage inflation on an average hourly rate basis for the year. If we think about the sequence of last year of inflation, it was high early in the year, began to moderate in the back half of the year where we saw wage inflation in the 3rd Q4 in the low 3 range. That has carried over into the Q1, although we expect for the year, there could still be some pressure on wages and maybe some potential in individual markets, maybe not across the board, but in certain markets, we can see higher wage growth than other markets and we do believe there could be some pressure in the back half of the year. It is a nice start to the year and we think that's very favorable in terms of our outlook and where we could ultimately end up for the full year.

Speaker 2

Yes, Ben, I'll add on to that. This is Tim. I think the other item that we baked into our guidance was more of the in sourcing of some of these hospital based specialties and the higher average audio rate on those professionals. So with anesthesia, more in sourced ED and Hospice programs In our pipeline, we anticipate that we'll have some increase or have some impact on the average audio rate increase as well. We also have a good strong pipeline of physician recruitment into our clinics, which also hits our SWB line as well.

Speaker 2

And maybe the last comment that I would make in terms of

Speaker 4

the mix, as Tim mentioned, the mix of employees coming in, many at a higher rate that could drive that up. We've also been very effective at bringing in some allied health workers and changing or making changes to our care delivery model that allows us to treat patients with more LPNs, nursing assistants and making those adjustments clearly you guys have made some

Speaker 5

really good

Speaker 8

progress there. But I'm just you guys have made some really good progress there. But I'm just wondering if there are any risks of in sourcing, maybe could bringing in more ED in the hospitalist impair your ability to flex staff to volume fluctuations in any way? Or is that not a concern? Thanks.

Speaker 2

Sure, Ben. I'll start answering that one. I don't see any real risk in relation to that. We have a good mix of employed and contracted personnel. So some of the staffing mechanism is through a per diem or a per day rate type of arrangement.

Speaker 2

So that is pretty flexible in terms of how we run the model.

Speaker 4

Yes. We've mentioned this before and maybe it hasn't been completely clear, but even where we've in sourced these programs, not all of those physicians become employees, although the majority do. A number of those physicians are still 10.99 employees and that 10.99 expense is down in our other operating expenses still. So that gives us some of the flexibility, I think, to address what you're talking about.

Speaker 8

Makes sense. Thank you.

Operator

The next question will come from A. J. Rice with UBS. Please go ahead.

Speaker 9

Hi, everybody. First, I was just going to ask, when I look at some of your volume metrics, same store admissions up 3.8%, adjusted admissions 1.9% and surgeries up 0 4. It's a little unusual to see the inpatient side growing faster than it puts it in that the outpatient side. Can you comment on any dynamics you're seeing there? And was that surgery mix?

Speaker 9

Was there a divergence between what you saw inpatient versus outpatient on the surgeries?

Speaker 4

Sure. I'll start off and Tim, please feel free to jump We have done a lot of work around length of stay management. And by doing that, we've opened up capacity by getting patients appropriately discharged and timely. Particularly in those markets where we were able to add that capacity through length of stay management. So I think that has been a big favorable mover and has allowed us to grow inpatient at the faster rate this past quarter.

Speaker 4

As we look out for the remainder of the year, we've also, as Tim mentioned, opened up the bed tower in Knoxville, Tennessee on April 1. So that's going to give us some additional capacity going into Q2. And then we have the VET tower in Foley, Alabama that's opening up in the Q4. So we still see opportunities. We're growing both inpatient and outpatient, but still being able to bring in additional inpatient throughout the remainder of the year.

Speaker 2

Yes, I agree. And A. J, in terms of the surgery mix, we saw growth on both the inpatient and the outpatient side. So pleased to see that. On the outpatient side, I think we outpaced it on absolute numbers just with our ASC growth and our focus on driving some really strong outpatient surgical sites of care.

Speaker 2

So we're pleased to see that happen. Going back to the inpatient growth in the quarter, as Kevin said, the transfer center is performing as designed. We also added new specialties into markets where we had insights that we weren't able to accept those patients in prior periods. So it's good to see our service line and acuity agenda are really delivering better access to patients in the communities we serve and yielding the expected growth in acuity and revenues.

Speaker 9

That's great. And maybe my follow-up, just to ask you on the payer mix, it looks like managed Medicare was up about 90 basis points and fee for services was the one that was down. Can you comment are you seeing outsized volume growth in your managed Medicare or is it rate or what's driving that increase as a percent of revenues? And any update on just general contracting with managed care?

Speaker 4

Sure. So the volume increases are still being led by Medicare Advantage and substantially all of our Medicare business increases are all Medicare Advantage. What we did experience this quarter was a little more balanced growth between Medicare Advantage and commercial. I think we'd indicated in the Q4 that early part of 2023, MA was growing at about a 3 for 1 ratio to commercial in the 4th quarter. It improved to only a 2 for 1 ratio and we continued on in the first quarter at approximately that 2:one ratio growth.

Speaker 4

So some slowing in that Medicare Advantage Growth business. In terms of contracting, it's still early in the year, but we're seeing early signs that would probably point to similar rate increases for 2025 that we are experiencing and looking to or already have locked in for 2024.

Speaker 9

Okay. Thanks a lot.

Operator

The next question will come from Stephen Baxter with Wells Fargo. Please go ahead.

Speaker 5

Hi, great. Thanks. This is Nick on for Steve. So I wanted to follow-up a little bit on the payer mix question to start. So it looked like Medicaid mix was actually up

Speaker 7

a little bit year over year.

Speaker 5

So I wanted to see if that was more driven by an increase in Medicaid supplemental payments or actually a patient mix shift? And then maybe just an update on what you're seeing from Medicaid redeterminations? Thank you.

Speaker 4

Sure. The increase in Medicaid net revenue is primarily due to the Medicaid supplemental programs. So kind of in terms of dollars, Mississippi was the big change year over year. That program, which we've recognized $40,000,000 in Q4 for 6 months' worth as that program just got approved and was retroactive to July 1. One quarter's worth of that, that full program that was approved is about roughly $80,000,000 on an annual basis.

Speaker 4

So we recognized the first quarter's portion of that in Q1. There was 0 of that in last year's numbers. So that was the primary driver of Medicaid increase, although we did have an increase in small increase in Medicaid volume too during the quarter. In terms of redetermination, we're not really seeing any substantial impacts. I mean, there's certainly patients who are losing Medicaid insurance.

Speaker 4

We're seeing a slight uptick in self pay volume, but we're also seeing the uptick of commercial volume. So a portion of those patients who are losing Medicaid are picking up exchange business insurance or commercial insurance, that's far offsetting any of the negative impacts.

Speaker 7

Great. Thank you.

Operator

The next question will come from Andrew Mok with Barclays. Please go ahead.

Speaker 5

Hi. There's been a lot of discussion around the 2 midnight rule for MA plans and the impact that might have on acute hospitals. Would love to hear your take on the rule and if and when you would expect to see any impact from that. Thanks.

Speaker 4

Yes. We're continuing to evaluate. I know there's been some additional guidance put out there by CMS. At this point, I think it's still early and not sure that we can really quantify the impact. There's a number of kind of moving parts around that that include work that we're doing ourselves internally with a physician advisor program that we've stood up that allows us to ensure that we're getting better documented or the appropriate documentation.

Speaker 4

It also we've kind of brought in house the peer review process with the payers. Both of those things should be beneficial to us. Then this quarter, we also had the situation with changes breach and change. It indicated that they were going to no longer require pre authorization for certain services. So that weighs into the calculation in Q1 as well as then some of the regulation from CMS for the payers about 2 midnight.

Speaker 4

Throw all those in, I'm not sure. It's very difficult to differentiate the impact of each individual one. But I would say, at least on the margins, we saw a little bit of improvement in Q1. Overall, though, denials still continue to increase. So I think there's a little bit of continued pressure.

Speaker 4

We may see some benefit in one area, but there's continued pressure in other areas and even on the commercial side from denials. And so I'd just again say it's kind of difficult at this point to measure, but we're keeping a close eye on it and hope we see some more clarity later in the year.

Speaker 5

Great. Thank you.

Operator

The next question will come from Josh Raskin with Nephron Research. Please go ahead.

Speaker 10

Hi, thanks. Good morning. Looking at occupancy rates overall, they're up nicely from pre pandemic. I'm curious how much of that is due to change in portfolio over the last couple of years versus an organic excuse me, organic or same store improvement? And where does occupancy need to get to in your mind to get to that sort of 15% intermediate target on margins?

Speaker 2

Sure, Josh. This is Kim. I'll kick it off. In terms of the occupancy rate growth, we think that's driven through the items we mentioned previously, the growth of the transfer center, higher acuity services. There is some adjustment to the portfolio when we divest smaller, more rural hospitals with a higher bed count and a low occupancy rate.

Speaker 2

Obviously, that helps our stronger markets where we run higher occupancy rates to shine through. We don't necessarily have an internal target if you will because of the changes in the portfolio. The other part of the equation that makes it difficult for us to really track occupancy rates in an absolute basis is we also have outpatients in those beds, which are not factored into the occupancy rate calculation that you're seeing there. And we have seen a growth of our outpatient observation business over the last several quarters as you know across this industry. But in general, we are very, very focused on understanding the physical footprint of every one of our campuses to make sure that we're optimizing that footprint, decommissioning any spaces which may not be necessary so that we're not running any additional fixed costs that aren't necessary for whatever volumes we can bring into that healthcare system.

Speaker 10

Got you. That's helpful. And then just on supply expense, down about 80 basis points year over year despite sort of the shift to inpatient, continued increase in the acuity and things like that. So what's driving the supply expense improvements?

Speaker 2

Yes. I think there's

Speaker 4

a number of things driving some supply expense improvement. It's relatively flat on a per adjusted admission basis, which would indicate that we are stepping over inflation and managing that well. We're doing that with a number of supply chain initiatives that we have in place to ensure we're getting best pricing, taking advantage of scale and so forth. We are putting in our ERP, which we've talked about Project Empower. I can't say that we're realizing a lot of savings currently yet because we only have a handful of hospitals up and running at least through the Q1, and it's still relatively new, but it's positioning us with significantly improved information that will allow us to manage that expense going forward.

Speaker 4

Back to the quarter, payer mix, I think had or I'm sorry, surgical mix had probably a significant impact on our ability to manage that supply expense with fewer high dollar implant items during the quarter. And then with the growth in net revenue, the top line growth, I think had some dilutive impact on that calculation as a percent of net revenue, bringing in your Medicare Medicaid supplemental program revenue, as well as the inpatient and growth in kind of medical cases, which can have a lower supply cost is a percent of net revenue.

Speaker 10

Okay, perfect. Thanks.

Operator

This concludes our question and answer session. I would like to turn the conference back over to Mr. Tim Hynchon for any closing remarks. Please go ahead.

Speaker 2

Great. Thank you, Chuck, and thanks to all of you for joining our call today. We remain committed to achieving our goals for 2024 and look forward to updating you again at the midyear point. As always, if you have additional questions, you can reach us at 6154-657000. Thanks again, and have a great day.

Operator

The conference is now concluded. Thank you for

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