HCA Healthcare Q4 2022 Earnings Report

HCA Healthcare EPS Results

• Actual EPS: $4.64
• Consensus EPS: $4.79
• Beat/Miss: Missed by -$0.15
• One Year Ago EPS: N/A

HCA Healthcare Revenue Results

• Actual Revenue: $15.50 billion
• Expected Revenue: $15.51 billion
• Beat/Miss: Missed by -$17.26 million
• YoY Revenue Growth: N/A

HCA Healthcare Announcement Details

• Quarter: Q4 2022
• Date: 1/27/2023
• Time: N/A
• Conference Call Date: Friday, January 27, 2023
• Conference Call Time: 10:00AM 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 Q4 2022 Earnings Call Transcript

Key Takeaways

• Volume Growth: In Q4, same-facility admissions rose 3% year-over-year (non-COVID up 5%), with equivalent admissions up 5.4% and emergency room visits surging 11% versus the prior year.
• Labor Progress: Registered nurse turnover fell 26% in Q4 versus the prior four-quarter average and overall labor cost per hour remained stable as contract labor utilization declined.
• Portfolio Optimization: HCA closed two joint ventures—merging Sarah Cannon with McKesson’s cancer research entity and partnering its purchasing organization with Blackstone—to boost clinical trials and supply chain services.
• 2023 Guidance: The company forecasts revenues of $61.5–63.5 billion, adjusted EBITDA of $11.8–12.4 billion and diluted EPS of $16.40–17.60, with capital spending around $4.3 billion.
• Strategic Priorities: For 2023, HCA will tackle labor and capacity challenges, counter inflationary pressures, and accelerate growth through outpatient facility expansion, digital upgrades and care model innovation.

Presentation

[Operator]

Good morning, welcome to the HCA Healthcare fourth quarter 2022 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 Vice President of Investor Relations, Mr. Frank Morgan, please go ahead, sir.

[Frank Morgan, Vice President of Investor Relations at HCA Healthcare]

Good morning, welcome to everyone on today's call. With me this morning is our CEO, Sam Hazen, and CFO, Bill Rutherford. Sam and Bill will provide some prepared remarks, and then we'll take a few questions. Before I turn the call over to Sam, let me remind everyone that should today's call contain any forward-looking statements, they're 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. On this morning's call, we may reference measures such as Adjusted EBITDA, which is a non-GAAP financial measure. A table providing supplemental information on Adjusted EBITDA and reconciling net income attributable to HCA Healthcare Inc. is included in today's release.

[Frank Morgan, Vice President of Investor Relations at HCA Healthcare]

This morning's call is being recorded, and a replay of the call will be available later today. With that, I'll now turn the call over to Sam.

[Sam Hazen, CEO at HCA Healthcare]

All right. Good morning, and thank you for joining the call. We finished 2022 as expected with pre-pandemic seasonality demand norms driving solid volume growth. Additionally, we continue to see progress with our labor agenda. These factors help produce solid earnings in the fourth quarter that were consistent with our guidance. We are encouraged by this outcome and believe this operational momentum should position us well for 2023. 2022 was a tale of two halves, with the first half being more about winding down from the previous two years of intense COVID activity and responding to the resulting challenges. The second half was more about normalization, which included strong demand and an improving labor market. Once again, I believe our people have demonstrated an impressive capability in the face of these dynamic forces and delivered for our patients, the communities we serve, and other stakeholders.

[Sam Hazen, CEO at HCA Healthcare]

Healthcare people in general are unique, but I believe HCA Healthcare people are even more special. I often refer to them as can-do people, and again, this past year, I think they proved it. I want to thank them for their hard work and everything they do each and every day for our company. Same-facility volumes across the company were strong in the fourth quarter. Admissions grew 3% year-over-year. Non-COVID admissions increased in excess of 5%. Equivalent admissions were up 5.4%, with impressive growth of 11% in the emergency room. Most of our other volume categories had solid growth metrics in the quarter also. The payer mix and acuity levels in the quarter remained at favorable levels. These factors produced revenue growth against a difficult comparison of 3% in the quarter.

[Sam Hazen, CEO at HCA Healthcare]

With respect to our people agenda, we were pleased with the improvements we saw in key metrics. Turnover numbers for registered nurses were down 26% in the fourth quarter as compared to the previous four quarters average. Our turnover rate is still higher than we want, we believe it is better than the industry average. Employee engagement scores recovered to around pre-pandemic levels. Again, our engagement is above the industry average. Our recruiting teams continue to generate results for the company. Hiring increased 6% year-over-year in 2022. Lastly, we opened our seventh Galen College of Nursing School this year. With respect to labor costs during the quarter, we experienced stable labor cost per hour with utilization of contract labor declining. As we have detailed in the past, we have implemented a robust human resources plan.

[Sam Hazen, CEO at HCA Healthcare]

We executed well on it and expect to make further progress as we move into 2023. It remains a top organizational priority. Even with the progress, we continued this quarter to experience capacity constraints, creating situations where we were unable to deliver services in certain situations. In the quarter, we saw value from our portfolio optimization plan and closed two joint ventures with strategic partners. One was with our Sarah Cannon Research Institute, which we combined with McKesson's cancer research entity. We believe the combination of these two entities will produce better cancer research and more clinical trials across the country, providing even more community-based resources for physicians and patients to fight this disease. The second co-venture is with our CoreTrust purchasing organization. We closed on a new partnership with Blackstone.

[Sam Hazen, CEO at HCA Healthcare]

We believe this new relationship can expand our ability to offer commercial purchasing and services solution to a broader variety of customers. We believe both of these deals achieved our strategic objectives and connected us with a better platform for success in the future. We are excited to partner with both entities. We also implemented our capital plan for the year as expected, including redeploying the proceeds from these two new joint ventures. Bill will provide more details in his comments. Finally, we announced in the last quarter a significant leadership transition that we believe will position the organization better with responding timelier to market dynamics while also strengthening the alignment of corporate functions to our strategy. The executives who are part of this transition are all proven HCA executives.

[Sam Hazen, CEO at HCA Healthcare]

They understand and appreciate our culture, and they know how to execute. We push ahead into 2023 and beyond, we believe the strong demand for healthcare services presents opportunity for HCA Healthcare in an otherwise challenging macro environment. We believe the company is well-positioned culturally, competitively, and financially to capitalize. Our agenda next year will be focused on the following three areas. First, overcoming labor and capacity challenges. Again, we believe we have the appropriate initiatives in place to respond to these. Second, counter inflationary pressures. Again, we have numerous efforts in place to contend with these forces while ensuring we continue to deliver high-quality outcomes to our patients. Third, accelerating growth with our winning plays. This agenda continues to leverage capital investments in outpatient facilities, clinical equipment for our physicians, and service line expansion.

[Sam Hazen, CEO at HCA Healthcare]

On top of our 2023 agenda, we are also making investments in our long-term plan, which includes four primary elements. The first one is advancing our clinical systems and digital capabilities. Second is transforming care models with innovative solutions. Third is expanding our workforce development programs. Fourth is investing capital in our networks to expand their offerings. These efforts are pressuring our results some in the current year, but we believe they are necessary in creating a platform for ultimately optimizing our networks, so they can deliver even better patient care in the future. Let me close with this. The last three years have been an extraordinary experience for everyone at HCA Healthcare. There's been no rest nor retreat for our people, and it was truly a challenge like no other.

[Sam Hazen, CEO at HCA Healthcare]

I strongly believe, however, that our board, our management teams, and our caregivers have shined through it all. We went into the pandemic with two priorities: to protect our people and to protect the organization, so we could continue providing high-quality health care to the communities we serve. I believe strongly that we showed up, we delivered on these priorities, and we did it the right way. I am proud of HCA Healthcare, and I'm even more proud of our people. The future for our company is even brighter because of the past three years and what we learned. Now, we will move into 2023 and the years ahead with greater purpose, with a renewed agenda to drive growth, and with more confidence in our ability to deliver value for all of our stakeholders.

[Sam Hazen, CEO at HCA Healthcare]

With that, I will turn the call to Bill, and he will discuss the quarter's results in more detail and our 2023 guidance.

[Bill Rutherford, CFO at HCA Healthcare]

Okay. Thank you, Sam, and good morning, everyone. I will provide some additional comments on our performance for the quarter and the year, then discuss our 2023 guidance. We finished the year with good volume metrics. Our fourth quarter same-facility admissions increased 2.9% over the prior year. For the full year, our same-facility admissions were up 0.5%. Excluding COVID admissions, our same-facility admissions grew 5.4% in the quarter and were up 3.4% for the year. For the full year, COVID admissions accounted for 5.2% of our admissions versus 7.8% in the prior year. Same-facility emergency room visits increased 11.4% in the quarter as compared to the prior year and were up 7.6% for the full year.

[Bill Rutherford, CFO at HCA Healthcare]

Our same-facility outpatient surgeries were up slightly in the quarter from the prior year. Increased 5.6% sequentially compared to the third quarter. Same-facility inpatient surgeries were basically flat as compared to the prior year. Both were impacted by one less business day in the quarter. Our same-facility revenue per equivalent admission was down 2.6% in the quarter from the prior year, as this was influenced by the drop in COVID activity. Sequentially, our non-COVID revenue per equivalent admission increased approximately 3.7% as compared to the third quarter. Our case mix increased just under 2% sequentially from the third quarter, and our payer mix remained stable as well. We remain pleased with our team's management of operating costs, even with the backdrop of higher inflation rates.

[Bill Rutherford, CFO at HCA Healthcare]

Our consolidated Adjusted EBITDA margins were 20.5% in the quarter and right at 20% for the full year. We continue to focus on our labor plans and supporting our teams while appropriately managing contract labor and premium pay programs. Our total labor cost as a % of revenue improved both sequentially and when compared to the prior year. In addition, our supply cost trends have remained very consistent during the year, and we are pleased with these results. Other operating expenses have been subject to some inflationary cost pressures when compared to the prior year, has run fairly consistent as a % of revenue throughout 2022. Our cash flow and capital allocation are a key part of our long-term growth and value creation strategies. Our cash flow from operations was $8.5 billion in 2022.

[Bill Rutherford, CFO at HCA Healthcare]

Our capital spending was just under $4.4 billion for the year, which was slightly higher than our initial expectations due to some year-end real estate and information technology purchases. We paid dividends of about $650 million, and we repurchased $7 billion of our outstanding stock during the year. Our debt to Adjusted EBITDA leverage ratio was near the low end of our stated leverage range of three-four times. For full year 2022, we realized approximately $1.2 billion in proceeds from sales of facilities and healthcare entities. Let me speak to our 2023 guidance for a moment. As noted in our release this morning, we are providing full year 2023 guidance as follows. We expect revenues to range between $61.5 billion and $63.5 billion.

[Bill Rutherford, CFO at HCA Healthcare]

We expect net income attributable to HCA Healthcare to range between $4.525 billion and $4.895 billion. We expect full year Adjusted EBITDA to range between $11.8 billion and $12.4 billion. We expect full year diluted earnings per share to range between $16.40 and $17.60. We expect capital spending to approximate $4.3 billion during the year. Let me provide some additional commentary on our guidance. Our 2023 Adjusted EBITDA guidance is impacted by several governmental and policy changes. In 2022, we recognized approximately $280 million in COVID support, mainly from DRG add-ons, removal of sequestration cuts, and HRSA reimbursement for uninsured COVID patients. We expect very little revenue from these programs in 2023.

[Bill Rutherford, CFO at HCA Healthcare]

Also, as discussed in our first quarter release, we recognized $244 million of revenues and $90 million of expenses related to the Texas Directed Payment Program that was for the last four months of 2021. This program that started on September 1, 2021 was not approved until the first quarter of 2022. In addition, we estimate the impact of the 340B related payment reductions to be between $50 million and $100 million. Adjusted for these items, the midpoint of our 2023 Adjusted EBITDA guidance would be in the middle of our historical 4%-6% growth expectations that we have had over time. Within our guidance, we expect our same facility equivalent admissions to grow approximately 2%-3% and our revenue per equivalent admission to grow approximately 2%.

[Bill Rutherford, CFO at HCA Healthcare]

Depreciation is estimated to be about $3.1 billion. Interest expense is projected to be around $1.975 billion. Interest expense will be impacted by both higher rates and anticipated draws under our revolving credit facilities. Our fully diluted shares are expected to be about 278 million for the full year, and cash flow from operations is estimated to range between $8.5 billion and $9 billion. Noted in our release this morning, our board of directors has authorized a new $3 billion share repurchase program. This will be in addition to the approximate $1.5 billion remaining authorization we had under the previous program at the end of the year. Our board has declared an increase in our quarterly dividend from $0.56 to $0.60 per share.

[Bill Rutherford, CFO at HCA Healthcare]

With that, I'll turn the call over to Frank, and we'll open it up for Q&A.

[Frank Morgan, Vice President of Investor Relations at HCA Healthcare]

Thank you, Bill. As a reminder, please limit yourself to one question so that we may give as many as possible an opportunity to ask a question. Devin, you may now give instructions to those who would like to ask a question.

[Operator]

At this time, I would like to remind everyone in order to ask a question, press star and then the number one on your telephone keypad. Our first question comes from Justin Lake with Wolfe Research.

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

Thanks. Good morning. Just a couple numbers questions here. Appreciate all the detail you've given. First, just all thinking about 2023, can you talk to us a little bit about what you're expecting for labor expense and maybe delineate the cost on permanent labor versus hopefully, you know, the downward trend. Maybe give us 22 versus 23 on temp labor. You know, a couple things, exchanges and redetermination, right? Exchange growth has been big. Redeterminations could be a tailwind, at least according to our estimates. Curious what you've assumed there on payer mix and kinda impacts from that on 2023 guide as well. Thanks, guys.

[Bill Rutherford, CFO at HCA Healthcare]

Yeah, Justin, this is Bill. Let me start. As it relates to labor cost, I think as a % of revenue, we'll keep it on an as-reported basis, flat with where we ran for the full year of this year. And so I think that's a good output for us. Relative to payer mix, we think payer mix for now will mostly remain stable. We are encouraged with what we are seeing with the enrollment in the health insurance exchanges, and we believe the enrollment in our states are probably a little bit higher than what we see as a nation.

[Bill Rutherford, CFO at HCA Healthcare]

We think we've contemplated that within the context of our overall range, but we are encouraged with some of the payer mix trends.

[Operator]

Our next question comes from A.J. Rice with Credit Suisse.

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

Hi, everybody, and thanks for the outlook commentary and so forth. Maybe, 'cause you've got about a $600 million range on the EBITDA range you're looking at. Can you maybe talk a little bit about what are some of the swing factors? Do you see those mainly as top line swing factors that would get you to the high or low end, or is there expense management open questions in your mind? Specifically on the labor, you've got quite a bit of a decline in the contract labor from what you spent in 2022 versus presumably the run rate for 2023. How much of that are you baking into the guidance versus how much are you saying you've got to redeploy to support permanent labor?

[Sam Hazen, CEO at HCA Healthcare]

A.J., this is Sam. I think on the guidance, I mean, we've got 2.5%, I believe, on either side of the midpoint. You know, the top side of that range, I think is achievable if our volume and labor agenda happens maybe a little bit better than what we anticipate. The low side of that range would be greater inflationary pressures and maybe some more challenges in a tenuous labor market. You know, those are sort of the big variables, if you will, in the equation. I mean, it's a fairly big number to begin with. Again, the 2.5% range on either side of the midpoint, we think is not unreasonable.

[Sam Hazen, CEO at HCA Healthcare]

To consider it to be very wide seems, you know, maybe to not fully appreciate some of the variables inside of it. With respect to labor, yes, we have made significant investments in our people. We did that throughout last year, mainly in the late summer, early fall, where we adjusted our wages to deal with movement in the market, resulting from some visibility that we had with our overall competitive positioning. Some of the contract labor reductions that we expect and have already made even will, you know, be absorbed a little bit in those decisions. We think the net of it is what Bill just alluded to, and that is that we can maintain our labor cost as a % of revenue, roughly around what we finished 2022 at.

[Sam Hazen, CEO at HCA Healthcare]

That's how we're thinking about it. Again, we're seeing positive metrics across the key dimensions of our labor agenda that is encouraging to us. We believe we have more room to gain with our agenda, and we're hopeful that will continue throughout 2023.

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

Okay, thanks.

[Operator]

Our next question comes from Gary Taylor with Cowen.

[Gary Taylor, Equity Research Analyst at Cowen]

Hi, good morning. two quick ones for me. Bill, I know you said, contract labor came down again, but I didn't catch if you disclosed the 4Q number. My other one was just also on your comment about the other OpEx line. I mean, that's still a line that on a per adjusted patient day basis is up in the double digits. Any help you can give us on thinking about modeling that for 2023?

[Sam Hazen, CEO at HCA Healthcare]

Yeah, Gary. On contract labor, you know, for the quarter, we were down about 16% from where we ran in fourth quarter of last year. Continued good improvement in that area. It represented roughly 7.8% of our total salary, wages, and benefits. We talked about giving that number before. Again, solid trends in the fourth quarter of this year compared to where we ran last year, and especially where we ran in the first half of the year. Our other operating expenses, you're right, are subject to some of the general inflationary increases that we're seeing across the economy. When we think about utilities and insurance and in addition, our professional fees areas, we're seeing some higher single digit cost growth and other operating expenses.

[Sam Hazen, CEO at HCA Healthcare]

Fortunately, if you look across the quarters for 2022 as a % of revenue, you'll see our other operating expenses as a % of revenue staying relatively flat and pretty consistent throughout the year. As we look forward to 2023, we do believe that's an area that could continue to see some higher single-digit inflationary pressures, and we factor that into our guidance going forward. Again, we think labor supplies will keep in line and hopefully below where our revenue growth is. The other operating cost areas around utilities, insurance, pro fees are gonna continue to see some pressures, and we factor that into our guidance.

[Operator]

Our next question comes from Ben Hendrix with RBC Capital Markets.

[Ben Hendrix, Equity Research Analyst at RBC Capital Markets]

Hey, good morning. Thank you. With regard to capacity constraints, you mentioned last quarter missing out on 1%-1.5% of total admissions, in 3Q. Can you give us an update on where that stands now? Maybe some more commentary on progress with your HR and case management initiatives. The degree to which you expect those to help ease constraints and support your guidance this year. Thank you.

[Sam Hazen, CEO at HCA Healthcare]

This, this is Sam. Thank you for that. I mean, we did, as I mentioned in my prepared comments, have some moments in the quarter where we were unable to receive transfers in or take certain patients into our facilities. That was actually a little bit elevated over the third quarter. We had roughly, using this as the proxy, approximately 2% of our total admissions we were unable to take through our transfer centers. They had to find those patients alternative solutions where we could. We were busier in the fourth quarter than we were in the third quarter. That was part of it.

[Sam Hazen, CEO at HCA Healthcare]

Nonetheless, we still are seeing opportunities for us to improve the throughput through our case management initiatives, as you spoke to, continue to increase the head count in our facilities in order to take care of these patients. We're hopeful that those numbers will start to come down a little bit as we push into 2023.

[Operator]

Our next question comes from Whit Mayo with SVB Securities.

[Whit Mayo, Senior Managing Director and Senior Research Analyst at SVB Securities]

Hey, thanks. Good morning. Sam, I wanted to go back to the long-term plan that you mentioned. You talked about advancing, you know, the transformation of care delivery models. Can you maybe elaborate more on that, sort of how that may be playing into the physician strategy, maybe a different view into working with within MA plans or anything would be helpful. Thanks.

[Sam Hazen, CEO at HCA Healthcare]

Well, let me give you a little bit of a backdrop on our long-term thinking with and I think this can help you understand why we are investing in these categories. You know, first and foremost, we think we have just an incredible portfolio of communities that we serve. They are growing in and of themselves, so we have opportunities to invest in that growth. We think demand is going to grow in our markets, aging baby boomers, population growth, chronic conditions, all those things unfortunately produce demand in some respects. We think our portfolio is a little better than the national averages on that front. We've got that as a backdrop. There's opportunities, I'll call it, outside the walls of HCA to invest in that natural growth in demand.

[Sam Hazen, CEO at HCA Healthcare]

The second piece that we believe exists is opportunities inside of HCA. We have what we call an economy of opportunities that exist across our 180 hospitals and 2,400 outpatient facilities that we have. That opportunity is to use big data, use better clinical system capability and better analytics to support better care. Our technology agenda, coupled with our care transformation agenda, is really about tapping into the economy of opportunity that exists inside our organization. We think we have two sets of opportunities: outside to continue to grow market share and benefit from the growth in our markets, and then continued improvement in care delivery for better patient outcomes, more efficiency, better operational management in our hospitals by infusing machine learning, advanced analytics with our care transformation agenda.

[Sam Hazen, CEO at HCA Healthcare]

Our care transformation team is led by a physician and a clinical team with industrial engineers and other type of people who are big data analysts who are supporting evaluating great performance that we have inside our company and really studying the processes around those or looking outside the company for better processes, better technologies, and again, weaving that into our overall agenda for our long run. We're encouraged by that. We have a major initiative that we're rolling out this year in our obstetrics unit, and we're excited about the possibilities around that. On our clinical systems, we're actually in our alpha pilot on our clinical system upgrade. We'll have a beta pilot later this year.

[Sam Hazen, CEO at HCA Healthcare]

This is a system that we will be able to push more information, standardized information into the cloud and start to turn that into actionable insights that we believe can help our patient outcomes. We're really excited about our long run agenda. Again, it's geared toward better patient care, but capitalizing on the opportunities inside the walls of HCA.

[Operator]

Our next question comes from Pito Chickering with Deutsche Bank.

[Pito Chickering, Managing Director and Senior Equity Research Analyst at Deutsche Bank]

Hey, good morning, guys. Thanks for taking my questions. Focusing on the fourth quarter, you talked about 2% lower admissions via the transfers. Were those all surgeries? I'm just trying to understand why inpatient surgeries are so weak on easy comps and why I didn't see a bigger increase in outpatient surgeries. We've seen some med tech companies report very strong U.S. surgical growth. Just trying to understand the delta. Also, what are you seeing you grow inpatient surgeries and outpatient surgeries in 2023? Thanks so much

[Pito Chickering, Managing Director and Senior Equity Research Analyst at Deutsche Bank]

Pito, this is Bill. I think our surgical volume, the thing that influenced that was we had one less business day, one less surgical day. You know, that could account for 1.5 or two of that trend. I don't think there's any other trends that we observed in our outpatient or inpatient surgery to call out other than just one less operating day. You know, going forward, I would say that, you know, we would anticipate our surgical volume to reflect our longer term trends, which has historically been somewhere around that two-point growth. Again, there's variables that fluctuate on that, but that was the issue on the flat surgical volume for Q4 was nothing other than one less surgical day.

[Operator]

Our next question comes from Kevin Fischbeck with Bank of America.

[Kevin Fischbeck, Director and Senior Equity Research Analyst at Bank of America]

Great. Thanks. I appreciate you guys breaking out kind of how you thought about the core pricing in the quarter. Is there a way to do that in the in the 2023 guidance?

[Kevin Fischbeck, Director and Senior Equity Research Analyst at Bank of America]

You know, obviously the COVID's a headwind, 340B is a headwind. You know, how to think about anything else that's a moving piece there. Just wanna understand the core trends in pricing, and then maybe talk a little bit about commercial rate growth and what you're renegotiating today. Thanks.

[Sam Hazen, CEO at HCA Healthcare]

Yeah, Kevin, let me start with that. As I said in my prepared remarks, we're anticipating revenue per equivalent admission around 2%. That's on an as-reported basis. Obviously, I called out some of those non-recurring revenue items we've had the benefit of in 2022, we don't expect to continue next year. If you adjust for those, that'd probably be pushing us towards the closer to 3% number, which would be, you know, historically, we would see 2%-3% growth. It really moves us back into our historical pricing trends, what we would see pre-COVID. It's just that we're having to jump over some of that loss of COVID. That was the 2% guidance in a revenue per equivalent admission. If you adjust that, it'd be closer to 3%, which is in line with our long-term guidance.

[Sam Hazen, CEO at HCA Healthcare]

That's contemplating both our Medicare rate updates with some improved commercial pricing that I think we've talked about in the past.

[Operator]

Our next question comes from Ann Hynes with Mizuho Securities.

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

Hi, good morning. I know some of your peers have noted that physician outsourcing services, especially on the ER, is a pressure point for 2023. Are you seeing that? If so, how much of a headwind is it to EBITDA? Secondly, just on the nursing turnover, I know you said that while you had a big improvement, you're still not where you wanna be. Can you talk about where you were for nursing turnover pre-pandemic, where you end at Q4, and maybe where you think you could end 2023? Thanks.

[Sam Hazen, CEO at HCA Healthcare]

Excuse me. Ann, it's Sam. We, pre-pandemic were somewhere around 13 or 14, excuse me, 14% for nursing turnover. We're on a run rate now, 18 and a half. That's down from mid-20s. We think the industry average is somewhere in the mid-to-upper 20s right now from what we've seen with external benchmarks and so forth. We're really encouraged by the progress our teams have made. Again, over the last six months of the year, we were starting to see improving trends. We believe we have the right initiatives in place to carry some momentum in that area into 2023.

[Sam Hazen, CEO at HCA Healthcare]

The market, as I mentioned, is a bit tenuous still, but, we're encouraged by the investments we've made in our recruiting, the investments we've made in retention and leadership training, and just the, I'll call it the hand-to-hand combat that exists in, making sure that our employees have the resources on their units that are necessary for them to deliver great care to their patients and for them to be successful in whatever their role is in the company. We think we're making progress on pretty much all of those fronts.

[Bill Rutherford, CFO at HCA Healthcare]

Ann, on the emergency room, I broadened it to, you know, more than emergency room, just hospital-based physician we have talked about in the past. We are seeing some increased pressures for subsidies around emergency room and anesthesiologists and the like. We have a number of initiatives to try to counter those. Yes, we are expecting some upward pressure in those areas that we factored into our guidance. It rolls through, as I mentioned in a previous question, in our other operating expenses, and we could potentially see, you know, higher single-digit year-over-year growth in those categories, probably at a little bit of pace above our revenue. We think we've made appropriate consideration for those trends inside of our guidance.

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

All right. Thanks.

[Sam Hazen, CEO at HCA Healthcare]

Yeah.

[Operator]

Our next question comes from Brian Tanquilut with Jefferies.

[Brian Tanquilut, Senior Equity Research Analyst at Jefferies]

Hey, good morning, guys. I guess, Sam, follow-up to Ann's question, to Bill's answer that, I saw that you exercised the call option in the Envision in JV last week. Just curious, how are you thinking about operationalizing that, and what would change for HCA as you bring those physicians back in-house? Maybe just thoughts on the P&L and balance sheet impact of that as well. Thanks.

[Sam Hazen, CEO at HCA Healthcare]

We've had a wonderful relationship with Envision over the years, and it continues to be strong across different facilities in our company. A number of years ago, we had made an investment in a co-venture with them that we felt was an opportunity for us to integrate that physician service, mainly in the ER and hospitalist medicine and a few other subspecialty categories within our hospitals as more clinically aligned and so forth. What we see is an opportunity to further that, we are moving to acquire a larger percentage of that co-venture, and we think it will give us a little better visibility in how to achieve better clinical integration to improve quality.

[Sam Hazen, CEO at HCA Healthcare]

We think we can use that platform to improve efficiency within our emergency rooms, primarily, and even on our med-surg floors where our hospitalists work. It will support graduate medical education in some innovative ways, we believe. We think it offers up an opportunity for us to You know, advance our connections to our strategic outreach partners in ways that maybe we don't necessarily accomplish in the structure we have today. We are pushing through the final stages of that transaction. I think it's scheduled to close sometime in the spring. We will take the rest of the year to fully assimilate it, so to speak. As we get into 2024, we anticipate being able to execute more effectively on these categories.

[Operator]

Our next question comes from Stephen Baxter with Wells Fargo.

[Stephen Baxter, Senior Equity Research Analyst at Wells Fargo Securities]

Hi. Good morning. Just wanted to ask a follow-up on the 2023 guidance. I was hoping you could talk a little bit more specifically about your expectations on inpatient admissions. I guess first, how are you thinking about where the COVID figure goes in 2023 compared to the 5.2% of admissions in 2022? The implication being, you know, I'd love to hear how you're thinking about, non-COVID admission growth in 2023. Thank you.

[Bill Rutherford, CFO at HCA Healthcare]

Yes. I'll start with that. You know, we expect a continued decline of COVID admissions, you know, as you've mentioned, and I said in my prepared remarks, they represent about 5.2% of our total admissions this year. You know, we're thinking next year, probably somewhere between 3% and 4% of our total admissions. We believe, you know, right now our inpatient admission growth somewhere around that 2% number, and that's embedded within the equivalent admission guidance that I gave between 2%-3%. Again, we'll continue to monitor that as we go through the year. We continue to believe that there's strong demand in our markets, and we're positioned well to serve that demand. Inpatient volume, we're thinking hovering around 2%.

[Bill Rutherford, CFO at HCA Healthcare]

You know, outpatient revenue probably continue to grow in that mid-single digit level, and that helps us get to the 2%-3% equivalent admissions that our guidance entails.

[Operator]

Our next question comes from Scott Fidel with Stephens.

[Scott Fidel, Managing Director and Senior Equity Research Analyst at Stephens]

Hi. Thanks. Good morning. Interested if you can just recap for us what the non-COVID acuity and case mix trends were in 2022, and then what you're building in for your assumptions for 2023. Thanks.

[Bill Rutherford, CFO at HCA Healthcare]

I don't know if I have the case mix necessarily. We've seen relatively flat, as I recall, on the COVID case mix, right? Our non-COVID case mix improved about 2% sequentially from the third quarter to the fourth quarter going forward. Our revenue per equivalent admission was roughly flat for the year-over-year comparisons.

[Scott Fidel, Managing Director and Senior Equity Research Analyst at Stephens]

Bill, on the outlook for 2023.

[Bill Rutherford, CFO at HCA Healthcare]

For non-COVID?

[Scott Fidel, Managing Director and Senior Equity Research Analyst at Stephens]

Yeah.

[Bill Rutherford, CFO at HCA Healthcare]

Yeah, that would be embedded in our revenue per equivalent admission of about 2%. When you factor out the loss of the revenue items, I think as I mentioned earlier, that pushes us closer to 3%. That would be just a combination of all factors of acuity as well as payer mix and pricing trends underneath the portfolio.

[Sam Hazen, CEO at HCA Healthcare]

Bill, if I can add, I think it's important for everybody to understand that strategically, we continue to invest in programs, as I mentioned in my prepared comments. A lot of those programs are farther up the acuity ladder, if you will. They're more significant, programs. They're extensions of existing programs. As we get our footing, so to speak, with a mid-level program or an upper mid-level program, then we can move into a more acute level program, and that helps with our overall acuity statistic. That's part of our strategy. We're doing that on top of the same fixed cost platform. Our hospitals have the same fixed cost regardless of the acuity in many instances. If we can increase the acuity, we get operating leverage from that.

[Sam Hazen, CEO at HCA Healthcare]

Strategically, that's a very important initiative of ours. The transfers in that we haven't been able to take care of tends to be slightly more acute than our average in most instances. Here again, that's why it's so important for us to get more employees across the organization to take care of these patients who need our services. All that's embedded inside of a real strategic initiative that we have.

[Scott Fidel, Managing Director and Senior Equity Research Analyst at Stephens]

Okay. Thank you.

[Operator]

Our next question comes from Calvin Sternick with JPMorgan.

[Calvin Sternick, Vice President, Equity Research at JPMorgan Chase & Co.]

Hey, good morning. Looks like another strong quarter for ER volumes. Can you talk a bit about the trends you've seen there the last few quarters in terms of payer and acuity mix and what you're expecting for 2023? Sort of related, you know, as you think about the volume trends across the business over the last couple of quarters, are there any service lines or categories that have either over or underperformed relative to your expectations? Any color you can give on those going into 2023? Thanks.

[Sam Hazen, CEO at HCA Healthcare]

This is Sam. Let me speak to some of our service lines trends. You know, during the pandemic, we thought the emergency room might be disrupted from what our previous beliefs were. There was, you know, new uses of telemedicine, you know, alternatives that were being experienced, we thought what we've seen is just the opposite. The resiliency of the emergency room for communities is even greater than we thought. The demand there is very strong because our emergency rooms and other people's emergency rooms are a solution set for people whenever healthcare is needed. Our trends in the emergency room have been very solid over the course of the year. When you look at them, really without the COVID activity, it's especially impressive, I think. We have seen good volume growth in our orthopedics.

[Sam Hazen, CEO at HCA Healthcare]

Our total joint business for the quarter was up 6%. In many instances, we fully absorbed, we believe, most of the shift over the last 3 years during the pandemic, with the orthopedic business moving from inpatient to outpatient. In most instances, we believe the large majority of that is behind us. We don't have that as a pressure point like we've had over the past three years. Nonetheless, we've grown that business in the face of the site of care shift. We have a very robust pipeline for our emergency rooms, especially our freestanding emergency room platform. Very significant development opportunity there for us across our communities, and we're investing in that. Our urgent care center platform continues to grow. We're up to 260 urgent care centers.

[Sam Hazen, CEO at HCA Healthcare]

We will probably push through 300 in 2023. Our ambulatory surgery center platform continues to grow. Here, again, we have more de novo development inside of our ambulatory surgery center platform than we've had in the past, and we're encouraged by how that fits into our networks in a very productive way. We're really pretty excited about our investments in our ambulatory network, our investments in our acuity programs, and our, and our higher service lines. We will continue to, we believe, be well-positioned to deal with the growing demand that we see in the market.

[Operator]

Our next question comes from Lance Wilkes with Bernstein.

[Lance Wilkes, Senior Analyst at Bernstein]

Yeah. Could you just talk a little bit about permanent nurses and understand the retention rates are getting better there. Can you talk a little bit about new hirings? What's sort of growth you're seeing there? What are maybe some of the drivers of access to nurses there? Where are they coming from? Also, if you could just talk a little bit about, you said the investment spend was pressuring on the long-term plan, was pressuring 2022 a little bit. Can you talk a little bit about how 2023 might look compared to 2022 with that? Thanks.

[Sam Hazen, CEO at HCA Healthcare]

Why don't you take, Bill, the last question?

[Bill Rutherford, CFO at HCA Healthcare]

Yeah, this is Bill on the investments. You know, when you think about the technology investments, the investments we're making in some of the clinical transformation. I'd also say with the expansion of our nursing schools going forward, probably is somewhere around an incremental investment of $150 million in 2023 compared to what we ran in 2022. All in, we didn't call that out, but it's part of a long-term investment we think that will continue to drive performance and value for us.

[Sam Hazen, CEO at HCA Healthcare]

Our hiring in 2022 was up a little north of 6%, just a huge number of new hires. That's the total number, just as a starting point. You know, where that is coming from, that's coming from new grads. There still is a decent pipeline of new graduate nurses in our communities. We have academic partnerships with different colleges beyond Galen that are important to that pipeline. We are also seeing some travelers decide that, "Okay, enough. We traveled. We want to come back," and we've been able to recover some of the employees who traveled in for a period of time back into our organization. We continue to be focused on trying to recover them.

[Sam Hazen, CEO at HCA Healthcare]

I think, again, with our benefits and with our wage adjustments and all the investments we're making in clinical education and other components of our labor agenda, we're starting to see, you know, more favorable trends in our recruitment function that we think, if they carry into 2023 and through the year, should be positive for us.

[Lance Wilkes, Senior Analyst at Bernstein]

Great. Thanks.

[Operator]

Our next question comes from Jason Cassorla with Citigroup.

[Jason Cassorla, Equity Research Analyst at Citigroup]

Great. Thanks for taking my question. I just wanted to ask a bit more on your capital priorities. You know, you've recently divested ownership in some hospitals, but just wondering, you know, how you're viewing the M&A backdrop, and if you're seeing opportunities to increase your footprint in your current markets, or potentially entering into new markets. Just on share repurchases, you know, you've increased your authorization by $3 billion. You have $4.5 billion left remaining. But just in light of the $7 billion you did this year, just curious how you're thinking about share repurchases in the context of your larger capital deployment priorities. Thanks.

[Bill Rutherford, CFO at HCA Healthcare]

Yeah. Let me take This is Bill. Let me take the latter one first. You know, I think share repurchases, an important part of our overall balanced capital allocation. As you mentioned, we did $7 billion in 2022. We'll have authorization close to $4.5 billion. I think we plan on, you know, completing the majority of it sometime in this calendar year with a little bit of roll forward afterwards. Again, we'll continue to adjust as kind of market conditions present. A share repurchase program has just been part of our overall balanced allocation of capital going forward.

[Sam Hazen, CEO at HCA Healthcare]

For M&A, we have been fairly active in market with outpatient acquisitions, again, when they come available, whether it's urgent care, some freestanding emergency rooms, some ASC, some physician clinics, and so forth. Those are very complementary, synergistic to our network, acquisitions, and we will continue to pursue those as they develop. We have not had too many opportunities on hospital acquisitions, although, recently there was an announced LOI on a hospital just outside of the Dallas-Fort Worth market that we think is synergistic with respect to clinical services and so forth, with our system in Dallas-Fort Worth. We'll continue to look for those. We do have a pipeline of greenfield hospitals because the acquisition environment is not as robust in market as maybe we would have hoped.

[Sam Hazen, CEO at HCA Healthcare]

We need to consider greenfield projects, and we do have a number of those that are in the works. We have one under construction currently in San Antonio, and I wanna say we have seven or eight parcels of land, maybe 10, that are designed for future hospital development when the time is right for us to make those investments.

[Operator]

Our next question comes from Steven Valiquette with Barclays.

[Steven Valiquette, Managing Director and Senior Equity Research Analyst at Barclays]

Thanks. Good morning, everybody. You know, just on the surgical volumes, you addressed most of the key questions related to the volumes for both the fourth quarter and the full year 2023. Just to follow up on that topic, I guess, a little bit more, I was just curious whether or not you do see any notable pent-up demand for any surgical cases exiting out of 4Q22 that might be flowing at least into the early part of 2023 for various reasons. Just curious on any visibility on early 2023 at this stage. Thanks.

[Sam Hazen, CEO at HCA Healthcare]

It's hard for us to really judge the whether there's demand on the sidelines, and we don't see it. I mean, we get some anecdotal information from our physicians who might indicate that, okay, their clinic patient profiles were better in the fourth quarter than they were at any point in time in 2022. I don't know if that's a precursor or not for pent-up elective surgical demand. I think we're just gonna have to wait and see. I believe it's a positive metric and a positive anecdote that their clinic roles, patient roles, appear to be at a higher level than they were in previous parts of 2022.

[Steven Valiquette, Managing Director and Senior Equity Research Analyst at Barclays]

Okay, great. Thanks.

[Operator]

Our next question comes from Jamie Perse with Goldman Sachs.

[Jamie Perse, Equity Research Analyst at Goldman Sachs]

Hello. Thank you. Good morning. Just a follow-up on the commercial reimbursement dynamics. You know, first, can you remind us what % of contracts have been recently negotiated that will take effect at the higher rates January first? Secondly, can you give us a little bit of color on what the initial bump in those contracts looks like relative to the rate escalators that are locked in place for the next couple of years? Thank you.

[Sam Hazen, CEO at HCA Healthcare]

We have, I wanna say, Bill, maybe 70% of our contracts for 2024 contracted. I will tell you that most of the contracts, if not all of the contracts we closed in the last 3 quarters of 2022 were in line with our expectations, which was around mid-single-digit inflators. Those have to work their way into the 2023 portfolio of contracts and on into the 2024. We are encouraged by the outcomes of those negotiations. I think there's a general recognition in the payer community that the input costs for providers are up. Given those inflationary pressures, they recognize that there's a sensitivity to responding to that, and we're trying to be appropriate in our ask.

[Sam Hazen, CEO at HCA Healthcare]

I think that's been received well, and we've been able to close these contracts reasonably timely. We still have, you know, 30% or so of 2023 that will get negotiated over the first part of this year. It will carry us through the all of 2023 and on into 2024. We're about 40% contracted on 2024. Again, the tail effect of some of the closed contract negotiations that we've just achieved will carry into 2024.

[Operator]

Our next question comes from Joshua Raskin with Nephron Research.

[Joshua Raskin, Research Analyst at Nephron Research]

Hi. Thanks for taking the question. I know CapEx guidance for 2023 is only down slightly, and I know it's still January, but it'd be the first time in, you know, a long time that CapEx would be down year-over-year, not counting 2020. I was wondering if you could just speak to any changes in budgeting or strategy or, you know, if there's anything that could be tempering that investment.

[Sam Hazen, CEO at HCA Healthcare]

John, I don't think there's anything tempering the investment at all. I think $4.3 is our expectation. As I mentioned in my comments, we initially expected $4.2. For 2022, it came in a little higher because we had some year-end activity that I mentioned around some real estate and some IT. I wouldn't read anything from down to the $4.4-$4.3. It's actually up.

[Sam Hazen, CEO at HCA Healthcare]

Compared to where our initial expectations are. As a summary, we still see very good opportunities to deploy capital, we believe, to capture growth opportunities in the marketplace. We've talked about some of that, whether that be through our freestanding EDs, whether it's in development of new hospitals, whether it be expansion of campuses. Again, I think it's an important part of our overall capital allocation, and I think an important part of our continued long-term focus on growing.

[Operator]

Our next question comes from Andrew Mok with UBS.

[Andrew Mok, Executive Director at UBS]

Hi. Good morning. I was hoping you could provide a bit more color on the supply cost trends into 2023. What are the assumptions around unit cost increases for supplies, and what steps did you take to manage inflationary pressure for multi-year contracts? Thanks.

[Bill Rutherford, CFO at HCA Healthcare]

Yeah. Well, thank you for the question. Our teams and our supply chain teams have done an incredible job over the past 12 to 18 months on our supply cost portfolio and especially with the backdrop of inflationary increases. We've talked about through the year, we've been really seeing really positive trends and actually to keep our supply cost growth below our revenue growth. Much of that was because some of our contracts, 60% of our contracts or so was under firm pricing for the most of 2022. We look forward, I think our basic assumption is to continue to keep our supply cost as a percent of revenue flat from where we ran full year at 2023.

[Bill Rutherford, CFO at HCA Healthcare]

That would imply our supply cost per unit is somewhere around that 2% level, plus or minus a little bit. Again, we're expecting continued good results in that, and again, our team's doing a nice job. We can keep that supply cost as % of revenue flat with where we ran this year with the backdrop of inflationary. That's pretty positive. We have a number of initiatives underway that our teams use. Part of our benchmarking initiatives is to, you know, look at utilization and identify best practices across the organization. We also are looking at, you know, product selection, partnering with our clinical teams. We have a number of initiatives underneath our supply chain operations that are helping us to achieve those results, and we look forward to those continuing as we go into 2023.

[Operator]

Our final question comes from John Ransom with Raymond James.

[John Ransom, Managing Director at Raymond James]

Do you know how hard it is to be clever with a question after all these good questions?

[Bill Rutherford, CFO at HCA Healthcare]

Well, you'll figure something out, John.

[John Ransom, Managing Director at Raymond James]

Yeah. These are... Like, three of my questions got stolen in the last five minutes. Now where's the fairness? For me, if we think about as you reduce your labor turnover, so let's say it goes hypothetically from 25 to 20, how would that affect your labor cost per either per revenue or per unit? How does that factor into a savings algorithm for us to think about?

[Bill Rutherford, CFO at HCA Healthcare]

How it affects our revenue per unit?

[John Ransom, Managing Director at Raymond James]

No, no. I mean, the salary, either salary as a percentage of adjusted admits or salary as a percentage of revenue.

[Bill Rutherford, CFO at HCA Healthcare]

Yeah. Yeah.

[John Ransom, Managing Director at Raymond James]

If you reduce turnover by, say, 500 basis points, how would that affect the labor margin?

[Bill Rutherford, CFO at HCA Healthcare]

Well, in theory, it will flow through as reduction of our contract labor. The margin, if you will, on the contract labor as we replace, you know, an individual from a contractor to a employed one, is that we'll, you know, save that margin and be able to reinvest. What we've been able to do this year is reinvest back into our employed workforce, and that's part of that-

[John Ransom, Managing Director at Raymond James]

Okay

[Bill Rutherford, CFO at HCA Healthcare]

... that turnover level. I think all of that, John, I would say is incorporated if you look at the overall labor spends. I mean, there's a lot of components into that. As we said, we think, you know, we can maintain our labor costs a % of revenue where we are finished this year. You know, it's a function of reducing those premium labor and reinvesting back into our employed workforce and keeping that relatively flat year-over-year. I think that's a good result for us and allows us to continue to recognize the important work our employees do for us.

[John Ransom, Managing Director at Raymond James]

Thanks so much.

[Bill Rutherford, CFO at HCA Healthcare]

Thanks, John.

[Operator]

There are no further questions at this time. I now turn the call over back to Mr. Frank Morgan.

[Frank Morgan, Vice President of Investor Relations at HCA Healthcare]

Kevin, thank you for your help today. Thanks to everyone for joining us on this call. We hope you have a great weekend. I'm around this afternoon if I can answer additional questions you might have. Have a great day.

[Operator]

That concludes today's conference. Thank you for attending today's presentation. You may now.

Participants

Executives

• Bill Rutherford, CFO
• Frank Morgan, Vice President of Investor Relations
• Sam Hazen, CEO

Analysts

• A.J. Rice, Managing Director and Equity Research Analyst at Credit Suisse
• Andrew Mok, Executive Director at UBS
• Ann Hynes, Managing Director and Senior Equity Research Analyst at Mizuho Securities
• Ben Hendrix, Equity Research Analyst at RBC Capital Markets
• Brian Tanquilut, Senior Equity Research Analyst at Jefferies
• Calvin Sternick, Vice President, Equity Research at JPMorgan Chase & Co.
• Gary Taylor, Equity Research Analyst at Cowen
• Jamie Perse, Equity Research Analyst at Goldman Sachs
• Jason Cassorla, Equity Research Analyst at Citigroup
• John Ransom, Managing Director at Raymond James
• Joshua Raskin, Research Analyst at Nephron Research
• Justin Lake, Analyst - Healthcare Services at Wolfe Research
• Kevin Fischbeck, Director and Senior Equity Research Analyst at Bank of America
• Lance Wilkes, Senior Analyst at Bernstein
• Pito Chickering, Managing Director and Senior Equity Research Analyst at Deutsche Bank
• Scott Fidel, Managing Director and Senior Equity Research Analyst at Stephens
• Stephen Baxter, Senior Equity Research Analyst at Wells Fargo Securities
• Steven Valiquette, Managing Director and Senior Equity Research Analyst at Barclays
• Whit Mayo, Senior Managing Director and Senior Research Analyst at SVB Securities