Community Health Systems Inc (CYH) 2023 Q4 法說會逐字稿

Ladies and gentlemen, thank you for standing by for the Community Health Systems fourth quarter and full year 2023 earnings conference call. The call will begin momentarily. Please stay on the line. Thank you.

女士們、先生們，感謝你們出席社區健康系統 2023 年第四季和全年財報電話會議。通話將立即開始。請保持通話。謝謝。

Hello, and welcome to the Community Health Systems fourth quarter and full year 2023 earnings conference call. (Operator Instructions) I would now like to hand the call to Anton Hie, Vice President of Investor Relations. Please go ahead.

您好，歡迎參加社區健康系統 2023 年第四季和全年財報電話會議。（操作員指示）我現在想將電話轉給投資者關係副總裁 Anton Hie。請繼續。

Thank you, MJ. Good morning to welcome to the Community Health Systems fourth quarter and year end 2023 conference call. Joining me today on the call are Tim Hingtgen, Chief Executive Officer; Kevin Hammons, President and Chief Financial Officer; and Dr. Miguel Benet, Executive Vice President of Clinical Operations.

謝謝你，喬丹。早上好，歡迎參加社區健康系統 2023 年第四季和年底電話會議。今天與我一起參加電話會議的是執行長 Tim Hingtgen；凱文‧哈蒙斯 (Kevin Hammons)，總裁兼財務長；以及臨床營運執行副總裁 Miguel Benet 博士。

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. 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-K 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.

在開始之前，我必須提醒大家，本次電話會議可能包含某些前瞻性陳述，包括所有不僅僅與歷史或當前事實相關的陳述。這些前瞻性陳述受到許多已知和未知風險的影響，這些風險在我們向 SEC 提交或提供的 10-K 表格年度報告和其他報告中的風險因素等標題中進行了描述。實際結果可能與今天討論中任何前瞻性陳述中表達的結果有很大不同。我們不打算更新任何這些前瞻性陳述。

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 to our website. All calculations we will discuss exclude gain or loss from early extinguishment of debt, impairment expense, as well as gains or losses on sales of subsidies came from the corporate transaction, expense from government and other legal matters and related costs, expenses from business transformation costs, expenses related to employee termination benefits and other restructuring charges and changes in estimates for professional claims liability related to the events and locations.

昨天下午，我們發布了一份新聞稿，其中包含我們的財務報表以及調整後 EBITDA 和調整後每股收益的定義和計算。我們還在我們的網站上發布了補充幻燈片演示。我們將討論的所有計算均不包括提前清償債務的收益或損失、減損費用以及公司交易中銷售補貼的收益或損失、政府費用和其他法律事務及相關成本、業務轉型成本費用、與員工解僱福利相關的費用和其他重組費用以及與事件和地點相關的專業索賠責任估計的變化。

With that said, I will turn the call over to Tim Hingtgen, Chief Executive Officer.

話雖如此，我會把電話轉給執行長 Tim Hingtgen。

Thank you, Anton. Good morning. Thank you for joining our fourth quarter and year-end conference call. To kick things off, I first want to recognize the more than 60,000 dedicated employees, providers, and leaders across our healthcare systems for the excellent care delivered to patients in 2023 and always.

謝謝你，安東。早安.感謝您參加我們的第四季和年終電話會議。首先，我首先要感謝我們醫療保健系統中 60,000 多名敬業的員工、提供者和領導者，他們在 2023 年及以後一直為患者提供了優質的護理。

I'd also like to acknowledge the tremendous team effort that enabled progress in every key priority established for 2023, which we have reviewed on these calls over the past several quarters. Throughout the year, we were purposely focused on advancing safe quality healthcare, strengthening our workforce, accelerating growth, and controlling expenses.

我還要感謝團隊付出的巨大努力，使 2023 年確定的每個關鍵優先事項都取得了進展，我們在過去幾個季度的電話會議中對這些優先事項進行了審查。在這一年裡，我們有目的地專注於推動安全優質的醫療保健、加強我們的員工、加速成長和控制費用。

Major accomplishments in the year included volume gains across all key services as we continued to see broad-based strength in demand. New access points, strong capacity management, defined workforce initiatives, and investments to optimize our competitive position made this growth possible.

今年的主要成就包括所有關鍵服務的銷售成長，因為我們繼續看到廣泛的需求強勁。新的接入點、強大的容量管理、明確的勞動力計劃以及優化我們競爭地位的投資使這一成長成為可能。

Same store admissions increased 3.5% in 2023, and adjusted admissions were up 5.3%, driving same store net revenue growth of 4.8%. Same store ER volume grew 1.1%, while surgeries increased a solid 5.1%. Adjusted EBITDA for the full year increased 12.3%, and our margin expanded 100 basis points year over year when excluding the positive impact of pandemic relief funds in 2022.

2023 年同店入場人數成長 3.5%，調整後入場人數成長 5.3%，推動同店淨收入成長 4.8%。同店急診量增加 1.1%，而手術量則穩定成長 5.1%。全年調整後 EBITDA 成長 12.3%，排除 2022 年疫情救助資金的正面影響，我們的利潤率年增 100 個基點。

When you consider a more than $200 million unanticipated increase in medical specialist fees and medical malpractice expense with 150 basis point impact to margin, we view this performance as a clear sign of positive momentum. We continue to invest in our core markets to accelerate growth prospects and further capture market share.

當您考慮到醫療專家費用和醫療事故費用意外增加超過 2 億美元並對利潤率產生 150 個基點的影響時，我們認為這一表現是積極勢頭的明顯跡象。我們繼續投資於我們的核心市場，以加速成長前景並進一步佔領市場份額。

In Knoxville, Tennessee, construction of our new tower is nearly complete with the grand opening scheduled to take place in the next few months. This project includes new inpatient beds and an expanded emergency department. On the Alabama Coast, the major expansion of our Baldwin County campus should open before the end of the year and will also increase the number of acute care beds and the surgical capacity available within this very busy hospital.

在田納西州諾克斯維爾，我們的新塔樓的建設已接近完成，預計在未來幾個月內舉行盛大的開幕儀式。該計畫包括新的住院床位和擴大的急診室。在阿拉巴馬州海岸，我們鮑德溫縣校區的主要擴建項目應在今年年底前開放，並將增加這家非常繁忙的醫院的急診床位數量和手術能力。

While we pursue bed additions where we are seeing strong demand and our growing market share, we also continue to invest in outpatient access points, such as ambulatory surgery centers, freestanding emergency departments, urgent care centers, and provider clinics. As a result, CHS health systems are capturing patient care that is migrating out of the inpatient environment, with 54% of our net revenues now derived from outpatient care.

在我們看到強勁需求和不斷增長的市場份額的情況下尋求增加床位的同時，我們也繼續投資門診接入點，例如門診手術中心、獨立急診室、緊急護理中心和提供診所。因此，CHS 衛生系統正在將病患照護從住院環境中轉移出來，目前我們淨收入的 54% 來自門診護理。

This outpatient focus includes the deliberate broadening of our ASC footprint. During the fourth quarter, we completed the expansion of the Grand View GI ASC in Birmingham, Alabama and completed an ASC acquisition in La Porte, Indiana. And already this year, we opened a de novo ASC in Cedar Park, Texas.

這種門診重點包括有意擴大我們的 ASC 足跡。第四季度，我們完成了阿拉巴馬州伯明罕 Grand View GI ASC 的擴張，並完成了印第安納州拉波特 ASC 的收購。今年，我們在德克薩斯州雪松公園開設了一家新的 ASC。

In addition to capital investments in our health systems, our transfer center is driving volume in higher acuity admissions, most notably in cardiology, critical care, GI, and general surgery. The transfer center also gives us visibility to see where we have opportunities to invest in further service line development and physician recruitment.

除了對我們的衛生系統進行資本投資外，我們的轉運中心還推動了高風險入院人數的增加，尤其是在心臟病學、重症監護、胃腸道和普通外科領域。轉運中心也讓我們能夠了解哪裡有機會投資進一步的服務線開發和醫生招募。

Work to sharpen our portfolio in 2023 included divestitures in West Virginia, Arkansas, Oklahoma, and Florida. As you may have seen, the FTC recently sued to block our planned divestiture of two hospitals in North Carolina to Novant Health. We are limited in what we can say at this point, but we believe this divestiture is appropriate and in the best interest of the community. The case will now move to Federal Court for final determination.

2023 年我們的投資組合優化工作包括剝離西維吉尼亞州、阿肯色州、俄克拉荷馬州和佛羅裡達州。正如您可能已經看到的，聯邦貿易委員會最近提起訴訟，阻止我們將北卡羅來納州兩家醫院剝離給 Novant Health 的計劃。目前我們能說的有限，但我們相信這種剝離是適當的並且符合社區的最大利益。該案現將移交聯邦法院進行最終裁決。

Proceeds from divestiture transactions enable a variety of positive activities, such as targeted investments in core markets, funding potential future acquisitions. and increased flexibility in debt management. We are currently evaluating inbound interest for a handful of markets that could yield more than $1 billion in additional proceeds. We have modeled several attractive scenarios, but we will remain extremely disciplined in our decision making as it relates to divestitures, acquisitions. and ensuring that our core portfolio is strong and positioned for long-term success.

剝離交易的收益可以促進各種積極的活動，例如對核心市場的有針對性的投資，為未來潛在的收購提供資金。並提高債務管理的靈活性。我們目前正在評估少數市場的入境興趣，這些市場可能會產生超過 10 億美元的額外收益。我們已經模擬了幾種有吸引力的場景，但我們在涉及資產剝離、收購的決策時將保持極其嚴格的紀律。確保我們的核心產品組合強大並且能夠取得長期成功。

In an effort to strengthen our workforce in 2023, our centralized clinical recruitment teams continued to deliver strong results, and we finished the year with a net gain of more than 1,000 bedside nurses. We also expanded their activities to Allied Health, building 1,500 physicians in clinical support, technician, and other roles. The impact was real with the $260 million reduction in contract labor in 2023 compared to the prior year.

為了在 2023 年加強我們的勞動力隊伍，我們的集中臨床招募團隊繼續取得強勁成果，全年淨增床邊護理師超過 1,000 名。我們還將他們的活動擴展到 Allied Health，培養了 1,500 名擔任臨床支援、技術人員和其他角色的醫生。與前一年相比，2023 年合約工減少了 2.6 億美元，這一影響是實實在在的。

Also, as you know, in 2023, we have rapidly and successfully insourced a large number of hospitalist and emergency medicine programs that were previously vendor outsourced. As a result, we now operate an internal infrastructure of resources that allows for further integration of hospital-based physician groups required by our markets. Based upon the success of insourcing ED and hospitalist medicine, initiatives are underway to insource anesthesia services in select markets, and we believe we can scale these new capabilities effectively and as needed.

此外，如您所知，到 2023 年，我們已快速成功地外包了大量先前由供應商外包的住院和急診醫學計畫。因此，我們現在運作著一個內部資源基礎設施，可以進一步整合我們市場所需的醫院醫生團隊。基於內包急診和住院醫學的成功，正在採取措施在選定的市場內包麻醉服務，我們相信我們可以根據需要有效地擴展這些新能力。

Advancing safety and quality is an ongoing daily commitment. In 2023, we achieved a record 89% reduction in our serious safety event rate from the baseline established more than a decade ago. We saw many other measures of quality care success, including a 25% reduction in the overall mortality rate and a 48% improvement in post-op respiratory failure rate. Looking to the future, our recently announced clinical data platform migration and partnership with Google Cloud opens the door for expanded use of AI and demonstrates how CHS is leveraging technology to drive administrative efficiencies and to improve patient care.

提高安全和品質是我們持續不斷的日常承諾。2023 年，我們的嚴重安全事件率較十多年前建立的基準降低了 89%，創歷史新高。我們看到了許多其他衡量優質照護成功的指標，包括整體死亡率降低 25%，術後呼吸衰竭率改善 48%。展望未來，我們最近宣布的臨床數據平台遷移以及與 Google Cloud 的合作為擴大人工智慧的使用打開了大門，並展示了 CHS 如何利用技術來提高管理效率並改善患者護理。

Dr. Benet is on the call with us today to comment about the ways we are and will be using AI and machine learning across our hospitals. Dr. Benet?

Benet 博士今天與我們通話，評論我們現在和將來在醫院中使用人工智慧和機器學習的方式。貝內特博士？

Thank you, Tim. Our partnership with Google Cloud enables us to unify our data into a single platform that facilitates greater transparency, enables more real-time decision-making, and that will serve as the foundation for the future use of AI in a healthcare setting. We call our platform THIA or tactical health engine for intelligent analytics.

謝謝你，提姆。我們與 Google Cloud 的合作使我們能夠將資料統一到一個平台中，從而提高透明度，實現更即時的決策，並將成為未來在醫療保健環境中使用人工智慧的基礎。我們將我們的平台稱為 THIA 或用於智慧分析的戰術健康引擎。

Working on this platform, we are developing tools that improve patient care and outcomes that support our clinicians and administrative teams in their work. As we leverage AI, we expect to drive efficiencies that enable our healthcare professionals to focus even more of their time on high-value patient interactions. For example, we can deploy this technology for continuous monitoring of patients in the acute care setting using algorithms and near real-time data to identify the potential need for early intervention. AI can be used to generate clinical summaries that physicians and nurses can edit for documentation, decreasing administrative work.

在這個平台上，我們正​​在開發改善患者護理和結果的工具，以支援我們的臨床醫生和管理團隊的工作。當我們利用人工智慧時，我們希望提高效率，使我們的醫療保健專業人員能夠將更多時間集中在高價值的患者互動上。例如，我們可以部署這項技術，使用演算法和近即時數據對急診環境中的患者進行持續監測，以確定早期介入的潛在需求。人工智慧可用於產生臨床摘要，醫生和護士可以對其進行編輯以形成文檔，從而減少管理工作。

Since AI can distill and disseminate large amounts of complex data, we anticipate using it to help our clinical documentation specialists to capture the complexity of care and documentation. Another example is our ability to provide patients with concise contextualized information to improve social determinants of health by using Google Maps capabilities to provide discharge patients with a list of nearby resources available in their communities and customized to their needs.

由於人工智慧可以提取和傳播大量複雜數據，我們預計使用它來幫助我們的臨床文件專家捕獲護理和文件的複雜性。另一個例子是，我們能夠使用 Google 地圖功能為出院患者提供其社區中可用的附近資源列表，並根據他們的需求進行定制，從而為患者提供簡明的情境信息，以改善健康的社會決定因素。

We are already seeing notable benefits, including improvements in a variety of quality metrics and operational benchmarks such as reductions in mental state. There are endless possibilities, and we are just beginning to see the power of artificial intelligence in healthcare. In all we are doing at CHS, we are following standards set in 2018 for ethical, safe, and proper use of AI and have joined the Coalition for Health AI to help frame safe and responsible use of AI in healthcare into the future.

我們已經看到了顯著的好處，包括各種品質指標和營運基準的改進，例如精神狀態的降低。存在著無限的可能性，我們才剛開始看到人工智慧在醫療保健領域的力量。在CHS 所做的一切中，我們遵循2018 年制定的關於道德、安全和正確使用人工智慧的標準，並加入了健康人工智慧聯盟，以幫助制定未來在醫療保健領域安全和負責任地使用人工智慧的框架。

Tim, I'll turn the call back to you.

提姆，我會把電話轉回給你。

Thank you, Dr. Benet. Our fourth overarching priority remains controlling expenses, which Kevin will address in his remarks, along with other comments about our financial performance in the fourth quarter and 2023 and our outlook for 2024. Kevin?

謝謝你，貝內特醫生。我們的第四個首要任務仍然是控制費用，Kevin 將在演講中談到這一點，以及有關我們第四季度和 2023 年財務業績以及 2024 年前景的其他評論。凱文？

Thank you, Tim, and good morning, everyone. Overall, we were pleased to see continued solid demand in our markets and CHS ongoing progress on our strategic priorities. For the fourth quarter, net operating revenues were $3.2 billion, representing year-over-year growth of 1.2% on a consolidated basis. On a same store basis, net revenue was up 4.1% over the fourth quarter of 2022, driven primarily by a 3.6% increase in adjusted admissions and a 0.5% growth in net revenue per adjusted admission.

謝謝蒂姆，大家早安。總體而言，我們很高興看到市場需求持續強勁，並且 CHS 在我們的策略重點方面不斷取得進展。第四季淨營業收入為 32 億美元，合併後年增 1.2%。以同店計算，淨收入較 2022 年第四季度增長 4.1%，這主要是由於調整後入場人數增長 3.6% 以及每次調整入場人次淨收入增長 0.5%。

Inpatient and outpatient volumes in the fourth quarter increased for both the commercial and Medicare books, reflecting the strong demand in our markets and targeted capital investments. However, the mix of that business with the disproportionate growth in Medicare Advantage versus fee for service and from states where our negotiated commercial rates are lower continued to affect our net revenue per adjusted admission growth similar to previous quarters.

第四季商業和醫療保險書籍的住院和門診量均有所增加，反映出我們市場的強勁需求和有針對性的資本投資。然而，該業務與醫療保險優勢與服務費的不成比例增長以及來自我們協商的商業費率較低的州的混合繼續影響我們調整後的入院淨收入增長，與前幾季度類似。

Adjusted EBITDA for the fourth quarter was $386 million, representing a margin of 12.1%. During the quarter, we benefited from the recognition of approximately $40 million in increased EBITDA from the Mississippi Hospital Access Program, of which approximately half related to prior periods. While this amount was not factored into our guidance, we effectively offset this benefit by increasing our self-insurance reserves for medical malpractice, which was recognized as a change in estimate during the fourth quarter. We believe this adjustment was appropriate based on recent experience and claims activity across the hospital industry.

第四季調整後 EBITDA 為 3.86 億美元，利潤率為 12.1%。本季度，我們受益於密西西比州醫院准入計畫增加的約 4,000 萬美元的 EBITDA，其中約一半與前期相關。雖然這筆金額沒有計入我們的指導，但我們透過增加醫療事故的自我保險準備金有效地抵消了這一收益，這被認為是第四季度估計的變化。根據整個醫院行業最近的經驗和索賠活動，我們認為這項調整是適當的。

Overall, we were pleased with our performance on labor costs. Average hourly wage rate for the quarter was up approximately 3% year over year, bringing the full year increase to approximately 4% versus our full year expectation for 5%. We expect similar growth in average hourly rate in 2024 or approximately 4%.

整體而言，我們對勞動成本的表現感到滿意。本季平均時薪年增約 3%，全年增幅約為 4%，而我們全年預期為 5%。我們預計 2024 年平均時薪將出現類似成長，即 4% 左右。

As Tim noted, our recruitment and retention strategies have helped stabilize our workforce, allowing us to drive significant reductions in contract labor expense, which at $52 million, represented an approximate $30 million decline over prior year and a modest decline sequentially. Recall that we typically see a material increase in contract labor utilization in the fourth quarter to help cover for seasonally higher patient demand.

正如Tim 指出的那樣，我們的招聘和保留策略幫助穩定了我們的員工隊伍，使我們能夠大幅減少合約勞工費用，合約勞工費用為5,200 萬美元，比上一年減少了約3,000 萬美元，比上年同期略有下降。回想一下，我們通常會看到第四季度合約勞動力利用率大幅增加，以幫助滿足季節性增加的患者需求。

Meanwhile, medical specialist fees at approximately 5% of net revenue remained elevated versus historical levels, but generally consistent with the third quarter. When comparing the gross up of expenses for physicians insourced from the former APP contract against the net revenue related to those physicians, we estimate that our results benefited by approximately $5 million during the quarter versus the subsidy payments previously paid to APP. We expect further opportunities in the coming quarters as we look to scale our insourcing efforts, but believe there continues to be pressure, particularly in the area of anesthesia.

同時，約佔淨收入 5% 的醫療專家費用仍高於歷史水平，但與第三季基本一致。當比較從前 APP 合約獲得的醫生的總費用與與這些醫生相關的淨收入時，我們估計，與先前支付給 APP 的補貼相比，我們的業績在本季度受益約 500 萬美元。隨著我們尋求擴大內包工作，我們預計未來幾季會出現更多機會，但我們相信壓力仍然存在，特別是在麻醉領域。

Cash flows from operations were $90 million for the fourth quarter of 2023 compared with $9 million in the year ago period. We did not see the expected improvements sequentially in accounts receivable, primarily from the temporary billing delays that we discussed last quarter related to clinical system upgrades and our physician insourcing initiatives.

2023 年第四季的營運現金流為 9,000 萬美元，而去年同期為 900 萬美元。我們沒有看到應收帳款出現預期的連續改善，這主要是由於我們上季度討論的與臨床系統升級和醫生內包計劃相關的臨時計費延遲。

Additionally, performance for the quarter was affected by growth in the Mississippi supplemental Medicaid program AR of approximately $40 million, the slowdown of receiving payments from Medicare Advantage payers versus fee for service of approximately $10 million, and the acceleration of interest payments resulting from our refinancing efforts of approximately $30 million. Note that we began receiving payments in the first quarter from the state of Mississippi for the expanded Medicaid funding program and expect significant further improvement in cash flows relative to where we finished 2023. Capital expenditures for the quarter were $110 million, bringing the full year total to $467 million, consistent with our guidance of $450 million to $500 million.

此外，本季業績還受到以下因素的影響：密西西比州補充醫療補助計劃AR 增長約4000 萬美元、從Medicare Advantage 付款人收到付款相對於服務費約1000 萬美元的放緩以及我們的再融資導致的利息支付加速約3000萬美元的努力。請注意，我們從第一季開始收到密西西比州擴大醫療補助資金計畫的付款，預計現金流量相對於 2023 年結束時將進一步顯著改善。本季資本支出為 1.1 億美元，使全年資本支出總額達到 4.67 億美元，與我們 4.5 億至 5 億美元的指引一致。

In December, we completed a private offering of $1 billion of 10.78% (sic - see press release, 10.875%") senior secured notes due 2032, using proceeds from the offering and from the completion of our prepared divestiture to redeem $985 million of our 8% notes due 2026 and to extinguish $402 million of principal amount of other debt, which by capturing discount, resulted in a pre-tax gain from early extinguishment of debt of approximately $72 million during the quarter.

12 月，我們完成了10 億美元、年利率10.78%（原文如此，見新聞稿，10.875%）、2032 年到期的優先擔保票據的私募發行，利用此次發行和完成我們準備的剝離所獲得的收益，贖回了我們9.85 億美元的債券。2026 年到期的 8% 票據，並消除了 4.02 億美元的其他債務本金，透過折扣，本季提前消除債務帶來了約7,200 萬美元的稅前收益。

Net debt to trailing adjusted EBITDA at year end was 7.88 times, slightly improved relative to the third quarter. We remain well positioned to meet our needs going forward with improved operations and $637 million of borrowing capacity under our ABL.

年末淨債務與調整後 EBITDA 比率為 7.88 倍，較第三季略有改善。透過改善營運和 ABL 下 6.37 億美元的借款能力，我們仍然能夠滿足未來的需求。

As Tim noted in his remarks, apart from the North Carolina transaction, we are currently evaluating opportunities for further divestitures across a handful of markets that could total more than $1 billion in additional proceeds. We anticipate that one or more of these transactions could close within the calendar year, providing substantial capital for the company to redeploy.

正如蒂姆在演講中指出的那樣，除了北卡羅來納州的交易外，我們目前正在評估在少數市場進一步剝離的機會，這些市場的額外收益總額可能超過 10 億美元。我們預計其中一項或多項交易可能會在一年內完成，為公司重新部署提供大量資金。

Project Empower, our enterprise modernization initiative, launched October 1. And after standing up our shared services platform and new workflows at 15 of our facilities with no disruption in patient care, we are seeing improved visibility and insight as expected. After a pause during the year-end closing process, we will begin further implementation throughout 2024.

我們的企業現代化計畫 Empower 計畫於 10 月 1 日啟動。在我們的 15 個設施建立了共享服務平台和新工作流程且沒有中斷患者護理後，我們看到可視性和洞察力如預期得到改善。在年度結算流程暫停之後，我們將在 2024 年開始進一步實施。

Moving on to our initial guidance for 2024, we anticipate net revenue of $12.3 billion to $12.7 billion, adjusted EBITDA of $1.475 billion to $1.625 billion, and cash flow from operations of $500 million to $650 million. When normalizing for the divestitures completed in 2023, the midpoint of our net revenue outlook represents a year-over-year growth of approximately 4%, and the midpoint of adjusted EBITDA represents a growth of approximately 9%.

繼續我們對 2024 年的初步指導，我們預計淨收入為 123 億美元至 127 億美元，調整後 EBITDA 為 14.75 億美元至 16.25 億美元，營運現金流為 5 億美元至 6.5 億美元。當 2023 年完成的剝離進行正常化時，我們的淨收入預期中位數年增約 4%，調整後 EBITDA 中位數成長約 9%。

Note that our outlook does not include the impact of any future divestitures or major acquisitions, does not include the impact of any debt refinancing transactions, and excludes the potential benefit from a rollback of the 163(j) limitation on interest deductibility for tax purposes in the income tax refund that we've previously discussed. Additionally, our cash flow guidance includes approximately $60 million to $80 million of cash outflow related to Project Empower. As the ERP and workflow modernization rolls out to the markets throughout 2024, these investments will wind down by year end and will become a cash flow tailwind into 2025.

請注意，我們的展望不包括任何未來資產剝離或重大收購的影響，不包括任何債務再融資交易的影響，也不包括因稅收目的而回滾 163(j) 利息扣除限制帶來的潛在利益。我們之前討論過的所得稅退稅。此外，我們的現金流量指引包括與 Project Empower 相關的約 6,000 萬至 8,000 萬美元的現金流出。隨著 ERP 和工作流程現代化在 2024 年推向市場，這些投資將在年底前逐漸減少，並將成為 2025 年現金流的推動力。

[Health] provide context for the 2024 adjusted EBITDA guidance relative to 2023 and 2022 as there are several puts and takes that we would like to highlight. Specifically, as we set initial guidance this time last year for 2023, we had anticipated adjusted EBITDA growth of approximately 7% at the midpoint. At that time, the primary expected headwinds were the $173 million reduction in pandemic relief funds and a moderate increase in medical specialist fees, which we were able to offset through the benefits of our margin improvement program, contract labor reductions, and growth inpatient volume.

[健康] 為 2024 年調整後的 EBITDA 指導（相對於 2023 年和 2022 年）提供了背景，因為我們想強調一些看跌期權和拿取金額。具體來說，當我們去年這個時候為 2023 年制定初步指引時，我們預期調整後的 EBITDA 中點成長率約為 7%。當時，主要的預期阻力是流行病救助資金減少 1.73 億美元，以及醫療專家費用適度增加，我們能夠透過利潤改善計劃、合約工減少和住院人數增長的好處來抵消這些阻力。

What we had not anticipated as we started 2023 was that medical specialist fees would spike as high as they did midyear, prior to our APP transaction, and that we would face additional headwinds from higher medical malpractice expense and from the outsized growth in Medicare Advantage as we have discussed in quarterly calls since then, leading to the results you see today.

在進入 2023 年時，我們沒有預料到的是，醫療專家費用將飆升至我們 APP 交易之前的年中水平，而且我們將面臨醫療事故費用增加和醫療保險優勢大幅增長帶來的額外阻力。從那時起，我們在季度電話會議中進行了討論，最終形成了您今天看到的結果。

Looking into 2024, we have much better visibility into these factors, while at the same time, we anticipate tailwinds from growth capital projects over the past two years, further reductions in contract labor, additional savings from cost control efforts, and a full year's benefit from the recently expanded Mississippi Medicaid funding program.

展望 2024 年，我們對這些因素有了更好的了解，同時，我們預計過去兩年增長資本項目的推動力、合約工的進一步減少、成本控制工作的額外節省以及全年的效益來自最近擴大的密西西比州醫療補助資助計劃。

Based on these factors, as well as operating results through the first six weeks of the year, we have a high degree of confidence in our ability to deliver on the guidance we have provided and look forward to providing updates in the coming quarters. Tim?

基於這些因素以及今年前六週的經營業績，我們對我們提供的指導的能力充滿信心，並期待在未來幾季提供更新。提姆？

Thank you, Kevin. I think now we're ready to open it up for Q&A.

謝謝你，凱文。我想現在我們已經準備好要進行問答了。

(Operator Instructions) Brian Tanquilut, Jefferies.

（操作員說明）Brian Tanquilut，Jefferies。

Hey, good morning, guys. Kevin, thanks for all the color that you gave us on the cash flow, but maybe just a little more detail just looking at the cash flow shortfall in Q4 and how you're thinking about guidance in 2024, including what seems to be a reduced CapEx spend for the year. So just any color you can share with us, and yeah, that would be great.

嘿，早上好，夥計們。凱文（Kevin），感謝您就現金流向我們提供的所有信息，但也許只是提供更多細節，看看第四季度的現金流短缺以及您如何考慮 2024 年的指導，包括似乎減少的金額本年度的資本支出。因此，您可以與我們分享任何顏色，是的，那就太好了。

Sure. Thanks for your question, Brian. So yeah, if I could just maybe go back through some of the items that I believe caused the shortfall in Q4 and then maybe talk a little bit about '24.

當然。謝謝你的提問，布萊恩。所以，是的，如果我可以回顧我認為導致第四季度短缺的一些項目，然後也許談談 24 年。

We finished Q3. I believe our accounts receivable balance was about $2.16 billion. We expected that to come down in Q4, particularly as we clawed back some of the buildup AR from our Cerner conversions.

我們完成了第三季。我相信我們的應收帳款餘額約為21.6億美元。我們預計這一數字將在第四季度下降，特別是當我們從 Cerner 轉換中收回了一些累積的 AR 時。

As we went throughout the quarter, although we clawed back maybe a third of that, we did not claw back all of that. We had some additional build up in AR, particularly around some of the insource positions as well as timing of some commercial payments. The holiday fell on a weekday, the last week of December, and we didn't really have complete insight into how some of the commercial payers may pay at the end of the year. So really, we look at that as just more of a timing issue.

在整個季度中，儘管我們收回了其中的三分之一，但我們並沒有收回全部。我們在 AR 方面做了一些額外的準備，特別是圍繞一些內源職位以及一些商業付款的時間安排。假期恰逢工作日，即 12 月的最後一周，我們並沒有真正完全了解一些商業付款人在年底可能如何付款。所以實際上，我們認為這更多的是一個時間問題。

And then the Mississippi program came through, which the cash of that wasn't paid in December, so I added that to our AR. And at the end of the day, the accounts receivable balance increased -- instead of decreasing, as we expected, had increased at the end of the year. So that was all in, call it, roughly $130 million headwind in cash flow in the fourth quarter.

然後密西西比計劃完成了，該計劃的現金在 12 月沒有支付，所以我將其添加到我們的 AR 中。最終，應收帳款餘額增加了——而不是像我們預期的那樣減少，而是在年底增加了。因此，第四季的現金流逆風約為 1.3 億美元。

Then we talked about we did a refinancing in the fourth quarter. We had to accelerate in the repayment of the bonds, accelerate some of the interest payments that otherwise would have been paid in '24. So it's clearly a timing issue because now that interest is paid, we will not have that payment in '24.

然後我們談到我們在第四季度進行了再融資。我們必須加快債券的償還速度，加快支付一些本應在 24 年支付的利息。所以這顯然是一個時間問題，因為現在已經支付了利息，我們將不會在 24 年支付這筆款項。

We also settled a legal case, the Mason case, which was about $30 million in the fourth quarter, made that payment, which was not anticipated, or we just did not know the timing of when that payment was made. We had it accrued at the end of the quarter but did not have the timing of when that payment would be made. So those are led to and are again primarily some timing-related matters.

我們還解決了一個法律案件，即梅森案，在第四季度支付了約 3000 萬美元的款項，這是我們沒有預料到的，或者我們只是不知道付款的時間。我們在季度末應計了這筆款項，但沒有確定付款的時間。因此，這些都是導致並且主要是一些與時間相關的問題。

As we go into the '24, a couple of things I'll just reiterate around the 163(j) interest deductibility. That has passed the house. It is in the Senate, although we don't know when or if the Senate will pass that rollback.

當我們進入 24 世紀時，我將重申有關 163(j) 利息扣除額的幾件事。那已經經過房子了。這是參議院的決定，儘管我們不知道參議院何時或是否會通過這一回滾。

So we've not anticipated, we've not put that in our guidance this year as well as the tax refund, which we still feel very comfortable that we're going to get, but we were wrong. I was wrong about anticipating the timing of that last year. So I'm not going to predict the timing of our government approving that this year.

因此，我們沒有預料到，我們沒有將其納入今年的指導以及退稅中，我們仍然對獲得退稅感到非常滿意，但我們錯了。去年我對這個時間的預測是錯的。因此，我不會預測今年政府批准該計劃的時間。

So if either of those come through, they would be positive. Our current cash tax estimate is $150 million to $200 million, and that could be reduced if either of those items come through.

因此，如果其中任何一個成功，它們都會是積極的。我們目前的現金稅估計為 1.5 億至 2 億美元，如果其中任何一項得以實現，現金稅可能會減少。

Got it. Okay. And then maybe as I think about just the expense line, any comment or anything you can share with us as it relates to your views on nurse wage inflation, contract labor utilization, what's baked into the guidance, and also physician service, or physician's specialists spend both inhouse and outsourced?

知道了。好的。然後，也許當我想到費用線時，您可以與我們分享的任何評論或任何內容，因為它涉及您對護士工資通膨、合約工利用率、指南中的內容以及醫生服務或醫生專家的看法內部支出和外包支出？

Yeah. So we're estimating a wage inflation at 4% for 2024. That's right about where we were at in 2023. So I think we've baked in a conservative estimate into '24 for wage inflation. And we'll certainly work harder to keep it below that, and we're actually exiting '24 at a rate below that. It was about 3.4% in Q4.

是的。因此，我們預期 2024 年薪資通膨率為 4%。這正是我們在 2023 年所處的位置。因此，我認為我們對 24 世紀工資通膨進行了保守估計。我們肯定會更加努力，將其保持在這個水平以下，而且我們實際上正在以低於這個水平的速度退出 24 年。第四季約為 3.4%。

On contract labor, again, as we look out at the midpoint of our guidance, assumes the current run rate that we're exiting '23 at -- if you think about $52 million fourth-quarter contract labor expense, if we stay at that run rate throughout '24, that would represent about a $60 million reduction in contract labor year over year, and about half of that would flow through to EBITDA. I do believe there's some opportunity that we can further reduce contract labor. It's still running significantly higher than pre-pandemic levels, and we still may be able to take a little bit more out of that.

再次，在合約勞工方面，當我們關注指導的中點時，假設當前運行率是 23 年退出的——如果你考慮到第四季度的合約勞工費用為 5200 萬美元，如果我們保持在這個水平按照2024 年全年的運行率計算，這意味著合約工年減約6000 萬美元，其中約一半將流入EBITDA。我確實相信我們有機會進一步減少合約工。它仍然明顯高於大流行前的水平，我們仍然可以從中獲得更多。

And then I think there was one more -- on CapEx, I think you had mentioned CapEx. We've had some higher CapEx over the past couple of years. We've had some large projects that were winding down. These are inpatient towers where we're adding inpatient capacity in markets where we need to add capacity. And because we're full and those markets are growing, those projects are winding down. So we'll have a year with a little less CapEx, also reflects the hospitals that we've divested over the past year. So we're still very comfortable with the amount of capital we're spending as well as trying to manage just our free cash flow.

然後我想還有一個問題——關於資本支出，我想你已經提到了資本支出。過去幾年我們的資本支出增加。我們有一些大型專案即將結束。這些是住院大樓，我們在需要增加容量的市場中增加住院容量。因為我們已經滿了，而且這些市場正在成長，所以這些項目正在逐步結束。因此，我們今年的資本支出將會減少一些，這也反映了我們在過去一年中剝離的醫院。因此，我們仍然對我們所花費的資本金額感到非常滿意，並努力管理我們的自由現金流。

Yeah. And Kevin, I'll tack on to that in terms of our philosophy and the management of our capital spending. We have a really full pipeline. We've talked about that a lot over the last several quarters. The predominant amount of that is on the outpatient side of the business, which we know does not typically have as high of a spend to get those strategic access points to put into operation. So that outpatient focus continues to be an area of growth and opportunity for us across the portfolio.

是的。凱文，我將在我們的理念和資本支出管理方面補充這一點。我們有一個非常完整的管道。在過去的幾個季度中，我們對此進行了許多討論。其中大部分是在業務的門診方面，我們知道門診方面通常不會有那麼多支出來使這些戰略接入點投入運作。因此，門診重點仍然是我們整個投資組合的成長和機會領域。

We're also managing that pipeline relative to the gains in staffing, so that when we are ready to activate the capital, bring it online, we have a cost-effective way to drive margin and payback on that capital investment. So we're really, I think, hyper focused on phasing this in ways that are really going to be accretive to earnings in the long run.

我們還根據人員配置的增加來管理該管道，以便當我們準備好啟動資本並將其上線時，我們可以採用一種具有成本效益的方式來提高資本投資的利潤和回報。因此，我認為，我們真的非常專注於以從長遠來看真正會增加收益的方式分階段進行這項工作。

The other thing I would point out is outside of CapEx, it's just keeping some of our powder dry for opportunistic acquisitions. So we'll keep an eye on that as things emerge in the upcoming quarters. On the outpatient side of the business, you heard me reference two outpatient ASC acquisitions later last year. We continue to scan our markets for those types of opportunities as well.

我要指出的另一件事是在資本支出之外，它只是為我們的機會性收購保留一些粉末。因此，隨著未來幾季的情況出現，我們將密切關注這一情況。在門診業務方面，您聽到我提到去年稍後對門診 ASC 的兩次收購。我們也將繼續掃描我們的市場，尋找此類機會。

Jason Cassorla, Citi.

賈森·卡索拉，花旗銀行。

Jason, I think we may have lost you.

傑森，我想我們可能失去了你。

Ben Hendrix, RBC Capital Markets.

本‧亨德里克斯，加拿大皇家銀行資本市場部。

Thank you very much. I wanted to follow up on the med mal reserving, specifically your decision not to adjust that out of adjusted results. And also, just your general comfort level with reserves where they are now. Is there anything out there specifically on the horizon that could continue to push those reserves up higher through the year? Just any comment around your thinking there. Thanks.

非常感謝。我想跟進醫療保留，特別是您決定不根據調整後的結果進行調整。而且，這只是您對儲備目前狀況的整體舒適度。是否有什麼特別的事情可以在今年繼續推高這些儲備？只是關於你的想法的任何評論。謝謝。

Sure. Thanks for the question, Ben. We debated whether or not it was appropriate to adjust that out of our adjusted EBITDA and certainly gave that to some consideration. At the end of the day, we decided to leave it in. We also had -- with Mississippi coming in, which was unexpected in the fourth quarter. We did not want to appear that we were cherry picking and only adjusting out unfavorable items.

當然。謝謝你的提問，本。我們討論了從調整後的 EBITDA 中調整這一點是否合適，當然也對此進行了一些考慮。最後，我們決定把它留在裡面。我們還得到了密西西比州的加入，這在第四季度是出乎意料的。我們不想讓別人覺得自己在精挑細選，只調整掉不利的項目。

There's reasons that Mississippi would stay in because it's an ongoing program. And we did not want to create a situation where we pulled it out also in the fourth quarter and then put it back in next year and just some inconsistencies. So at the end of the day, we just decided to leave them both into the adjusted EBITDA calculation. Again, the Mississippi program, like other programs, are ongoing and really represent reimbursement for services provided. So I think that's also appropriate.

密西西比州之所以會留下來是有原因的，因為這是一個正在進行的計劃。我們不想造成這樣的情況：我們在第四季度也將其撤出，然後在明年放回原處，並且只是出現一些不一致的情況。因此，最終，我們決定將它們都保留在調整後的 EBITDA 計算中。同樣，密西西比計劃與其他計劃一樣，正在進行中，並且真正代表了所提供服務的報銷。所以我認為這也是合適的。

As we look ahead to '24, the malpractice environment overall I think is getting more difficult. We're seeing some pretty large settlements, jury awards in cases that are higher than we've ever seen historically. And I think there is a little bit of pressure in the industry at large. We're hearing that from our insurance carriers as well.

當我們展望 24 年時，我認為整體醫療事故環境變得更加困難。我們看到一些相當大的和解，陪審團對案件的裁決比我們歷史上見過的要高。我認為整個產業都面臨一些壓力。我們也從保險公司聽到了這一點。

We are self-insured for malpractice with excess insurance coverage above certain levels. So we do have insurance. And here, there is some pressure there. But overall, I would expect our malpractice expense to probably come back to something a little more normal in the future as we manage through.

我們對醫療事故進行自我保險，超額保險範圍超過一定水準。所以我們確實有保險。在這裡，那裡有一些壓力。但總的來說，我預計，隨著我們渡過難關，我們的醫療事故費用將來可能會恢復到更正常的水平。

I'd also point out that the work we've done on patient safety and quality over the years and the 89% reduction in serious safety events that Tim called out is very meaningful. And there's such a long tail on malpractice. We're still settling a lot of old claims. But the rate at which new claims are coming in is significantly lower than it had been historically. So I feel good about the future and our ability to manage that cost.

我還要指出，我們多年來在病人安全和品質方面所做的工作以及蒂姆所說的嚴重安全事件減少了 89% 是非常有意義的。而且瀆職行為有很長的尾巴。我們仍在解決許多舊索賠。但新申請失業救濟人數的比率明顯低於歷史水準。因此，我對未來以及我們管理成本的能力感到滿意。

Thank you. And if I may, a quick follow-up on your comments about around puts and takes on guidance. I was wondering if we could get some more detail on the key drivers of margin improvement implied for 2024. It sounds like there will be some support from lower contract labor year over year, and you mentioned lower wage inflation, than we saw also Missisippi Medicaid. But should we also expect some normalization of payer mix trends this year? Any comments on how we bridge to the margin? Thanks.

謝謝。如果可以的話，請快速跟進您對看跌期權和看跌期權指導的評論。我想知道我們是否可以獲得有關 2024 年利潤率改善的關鍵驅動因素的更多詳細資訊。聽起來，合約工逐年減少會提供一些支持，而且您提到薪資通膨率低於我們看到的密西西比州醫療補助。但我們是否也應該預期今年付款人組合趨勢會出現一定程度的正常化？對於我們如何彌合邊緣有什麼評論嗎？謝謝。

Yeah, I do. And you called out a couple of the items already mentioned. I do think there's some or we have some expectation of some normalization in payer mix trends. Rates continue to be relatively favorable, governmental rate.

是的。您列出了已經提到的幾個項目。我確實認為，或者我們有一些預期，付款人組合趨勢會出現某種正常化。利率繼續相對優惠，政府利率。

Medicare lift should be in the 2.5% to 3% range this year versus 2023. It was 1.9%. I think Medicaid is about flat, excluding some of the supplemental programs. It was a negative in 2023. So those are all marginally helpful as commercial rates are still in that 4% to 6% range, similar to 2023, but another year of those should be helpful.

與 2023 年相比，今年醫療保險增幅應在 2.5% 至 3% 範圍內。是1.9%。我認為醫療補助計劃大致持平，不包括一些補充計劃。2023 年的情況是負面的。因此，這些都略有幫助，因為商業利率仍處於 4% 至 6% 的範圍內，與 2023 年類似，但再過一年應該會有所幫助。

As we continue to grow volume and cover -- and able to cover our fixed cost, that has the benefit of increasing our margin. And as our markets continue to grow and we continue to see recovery and higher volumes, I think that's an important factor to point out.

隨著我們不斷增加銷售量和覆蓋範圍，並且能夠涵蓋我們的固定成本，這有利於增加我們的利潤。隨著我們的市場持續成長，我們繼續看到復甦和銷售增加，我認為這是一個需要指出的重要因素。

We also have our margin improvement program that we're highly focused on and putting a lot of discipline around a number of initiatives. Some of those are baked into our guidance. Many of them are not baked into our guidance and give us the upside potential. But around the uncertainty of when those come through and to what degree, we did not want to get too far out ahead and bake all of that. But we have a number of initiatives we're working on that should be favorable.

我們也制定了高度關注的利潤改善計劃，並圍繞著許多措施制定了嚴格的紀律。其中一些已納入我們的指導中。其中許多並未納入我們的指導，也沒有為我們帶來上行潛力。但由於這些問題何時實現以及達到何種程度的不確定性，我們不想走得太遠並烘烤所有這些。但我們正在實施一些應該是有利的措施。

Jason Cassorla, Citi. Please go ahead.

賈森·卡索拉，花旗銀行。請繼續。

Great. Thanks. Can you guys hear me?

偉大的。謝謝。你們聽得到我說話嗎？

Yeah, sure we can. We hear you now, Jason.

是的，我們當然可以。我們現在聽到你的聲音了，傑森。

Excellent. Thank you. Apologies for that. I wanted to talk about the MA book. In the past, you've discussed how your MA book has a lower effective pricing yield compared to fee-for-service Medicare and how that dynamic has impacted results with your elevated M&A volume growth in '23.

出色的。謝謝。對此表示歉意。我想談談 MA 書。過去，您曾討論過與按服務收費的 Medicare 相比，您的 MA 書籍的有效定價收益率較低，以及這種動態如何影響您 23 年併購數量增長的結果。

But I guess stepping in the '24, are you anticipating any offsets to this yield differential, whether that be from a contracting perspective with MA payers or new rules like the two-midnight rule. I guess just if you have any color on the levers and areas that can help narrow that pricing yield differential moving forward.

但我想，進入 24 年，您是否預計這種收益率差異會得到任何抵消，無論是從與 MA 付款人簽訂合約的角度來看，還是從午夜兩點規則等新規則來看。我想只要你對槓桿和區域有任何顏色，就可以幫助縮小未來的定價收益率差異。

Sure. So when you go step back when we look at our contracts on a procedure by procedural basis, the rate of reimbursement is pretty similar to Medicare fee-for-service. The realization is really where we lose money comparatively, and that's what causes the discount that we talked about, and that's a result of downgrades and denials of claims.

當然。因此，當您退後一步，當我們逐程序查看我們的合約時，報銷率與醫療保險按服務收費非常相似。實現確實是我們相對虧損的地方，這就是導致我們談論的折扣的原因，這是降級和拒絕索賠的結果。

Going into '24, there certainly should be some benefit from the new guidance put out by CMS around the two-midnight rule around pre-authorizations. We expect that those could be helpful to us; it's too early to tell. We've not been able to quantify that yet and too early in '24 to really see that come through.

進入 24 年，CMS 針對預授權的午夜兩點規則發布的新指南肯定會帶來一些好處。我們希望這些對我們有幫助；現在說還太早。我們還無法量化這一點，而且在 24 年真正看到這一點還為時過早。

I know some of the payers have talked about already seeing an impact in Q4, making more payments. We did not see any benefit in Q4 from that coming through. But I think directionally, it could be positive for us in '24. Tim?

我知道一些付款人談到已經在第四季度看到了影響，支付了更多款項。我們沒有看到第四季度的任何好處。但我認為從方向上來說，這對 24 年的我們來說可能是正面的。提姆？

Yes, Jason, I think we're investing in a lot of clinical resources to help us monitor the environment, be more on the proactive side of this. We've talked in the past about our centralized [GR] investments. That was largely a registered nurse organized function under the direction of Dr. Benet.

是的，傑森，我認為我們正在投資大量臨床資源來幫助我們監控環境，並且更加積極主動。我們過去曾討論過我們的集中式 [GR] 投資。這主要是由註冊護士在貝尼特博士的指導下組織的活動。

Later last year, we stood up a physician adviser, insource physician adviser program to really be more active and proactive as much as we can be, but also to counteract any downgrades and denials that the admitting physician and the physician advisers believe is clinically appropriate for inpatient status. So we would expect to see some tail effects, positive tail effects for that in 2024 as well.

去年晚些時候，我們設立了一個醫生顧問，即內包醫生顧問計劃，以盡可能地更加積極主動，同時也抵消入院醫生和醫生顧問認為臨床上適合的任何降級和否認。住院狀態。因此，我們預期 2024 年會出現一些尾部效應，正面的尾部效應。

Okay, got it. Thanks. And maybe just a follow-up, and apologies if I missed this before, but I wanted to ask on that 4% revenue growth excluding divestitures. Can you just help on the building blocks of that 4% relative to your 2% to 3% target for volume and pricing and mix?

好，知道了。謝謝。也許只是一個後續行動，如果我之前錯過了這一點，我深表歉意，但我想問 4% 的收入成長（不包括資產剝離）。相對於 2% 到 3% 的銷售、定價和組合目標，您能否協助建立 4% 的基礎？

And then maybe just specifically on volumes, growth for 2023 was some, call it, 300 basis points ahead of your original expectations. Do you feel that the outsized growth last year creates a comp issue for you in '24, especially in the first half of the year? Or how would you frame the volume environment in '24? Thanks.

然後，也許只是就數量而言，2023 年的增長比您最初的預期高出 300 個基點。您是否認為去年的大幅成長為您帶來了 24 年的薪資問題，尤其是今年上半年？還是你會如何建構 24 世紀的體積環境？謝謝。

Yes. I would say that the 4% growth, we're looking at roughly 2% to 3% volume growth in '24, which is lower than we experienced in '23. But we still believe strongly that we can continue to grow those volumes in our markets and get something 2% to 3% volume growth.

是的。我想說的是，4% 的成長，我們預計 24 年銷量成長大約為 2% 到 3%，這低於我們在 23 年經歷的情況。但我們仍然堅信，我們可以繼續增加市場銷量，並實現 2% 至 3% 的銷量成長。

And then rate overall, as I mentioned, we're 4% to 6% on commercial rate, 2.5% to 3% on Medicare which is a little higher than we had in '23 and about flat on Medicaid. There probably is and we've factored in a little bit of a headwind on continued deterioration in payer mix. But when you throw all that in together, we get about a 4% same store growth on net revenue.

然後整體評級，正如我所提到的，我們的商業利率為 4% 至 6%，醫療保險利率為 2.5% 至 3%，比 23 年的水平略高，而醫療補助利率則持平。可能確實存在，而且我們已經考慮到了付款人結構持續惡化帶來的一些不利因素。但當你把所有這些加在一起時，我們的同店淨收入增加了約 4%。

A.J. Rice, UBS.

A.J.賴斯，瑞銀。

Hi, everybody. Just maybe to follow up a little bit more on that payer mix question. There's been obviously a debate in the marketplace about utilization rates. Are you seeing any difference in behavior among your utilization between your MA book and your fee-for-service book and frankly the rest of the book as well. Is there anything you can tell in terms of rebound post pandemic and so forth that may show different trends across those payer classes?

大家好。也許只是對付款人組合問題進行更多跟進。市場上顯然存在著關於利用率的爭論。您是否發現您的碩士書籍和收費服務書籍之間的使用行為有任何差異，坦白說，還有本書的其餘部分。在疫情大流行後的反彈等方面，您能看出什麼可能顯示出這些付款人階層的不同趨勢嗎？

I think post pandemic, we certainly saw a deterioration in the actions by the MA payers where they were not downgrading or denying claims during the pandemic. They certainly began denying and downgrading significantly more claims, particularly in the MA book, although it applies to commercial as well, but more so in the MA space.

我認為大流行後，我們當然看到了 MA 付款人的行為惡化，他們在大流行期間沒有降級或拒絕索賠。他們當然開始否認和降低更多的主張，特別是在 MA 書中，儘管它也適用於商業，但在 MA 領域更是如此。

And we believe that it hit a peak. And I think that's gotten a lot more attention at the governmental levels. We've certainly been active in our discussions with legislators, with our lobbying efforts. I know the American Hospital Association, Federation of American Hospitals, they've all tried to shine a light on some of the behavior of the payers. And I think that's resulted in some movement by CMS to come out with some additional guidance around their expectations, like the two-midnight rule, like some of the pre-authorization requirements.

我們相信它已經達到頂峰。我認為這在政府層面得到了更多的關注。我們當然一直在積極與立法者進行討論並進行遊說工作。我知道美國醫院協會、美國醫院聯合會，他們都試圖揭露付款人的一些行為。我認為這導致 CMS 採取了一些行動，圍繞他們的期望提出了一些額外的指導，例如午夜兩點規則，例如一些預授權要求。

We have yet to see any real change that's meaningful or measurable. But having said that, we do expect there to be some favorable movement into 2024.

我們還沒有看到任何有意義或可衡量的真正變化。但話雖如此，我們確實預期 2024 年將會出現一些有利的趨勢。

Yeah, A.J., this is Tim. I'll go back to my comment. The reason we set up the physician adviser program was to make sure that we're supporting the admitting physician's decision with more collaboration with the MA plans or commercial plans in general.

是的，A.J.，這是提姆。我會回到我的評論。我們設立醫師顧問計畫的原因是為了確保我們透過與 MA 計畫或一般商業計畫更多的合作來支持入院醫師的決定。

We have a strong compliance program across Medicare and every other payer source as well. But in general, to try to counteract some of those adverse trends, we believe we're better positioned going forward to make sure that that admitting physician's decision is more strongly represented.

我們在醫療保險和所有其他付款來源方面都有強大的合規計畫。但總的來說，為了試圖抵消其中一些不利趨勢，我們相信我們能夠更好地前進，以確保入院醫生的決定得到更強有力的代表。

Okay, thanks. And maybe my follow-up, just to ask about -- you're mentioning this divestiture activity that you plan to undertake. Is that in response to people proactively coming to you? Is it strategic decision you're making.

好的謝謝。也許我的後續行動只是想問一下——您提到了您計劃進行的剝離活動。這是對人們主動來找你的回應嗎？這是您正在做出的策略決策嗎？

And you talked about having as much $1 billion for capital deployment, I wondered whether you're thinking mainly about paying down debt further? Or is there some other use of that potential capital that you're thinking about?

你談到有多達10億美元的資金配置，我想知道你主要考慮的是進一步償還債務嗎？或者您正在考慮對潛在資本進行其他用途嗎？

So sure. Happy to take that one, A.J. So this is almost entirely resulting from inbound interest. But having said that, I still think we're taking an opportunistic look because we get inbound interest on a number of locations and facilities that we don't act on. So we're not acting on every inbound interest that comes in, but we do happen to have some inbound interest in markets that we think may make strategic sense to transact.

非常確定。很高興接受這個，A.J.因此，這幾乎完全是由入境興趣造成的。但話雖如此，我仍然認為我們採取了機會主義的態度，因為我們對許多我們沒有採取行動的地點和設施產生了興趣。因此，我們並不是對每個進來的興趣都採取行動，但我們確實在我們認為交易可能具有戰略意義的市場中碰巧有一些入境興趣。

So we're pursuing those further. We don't know at this point whether they'll come to fruition, but there is some significant interest out there that we are going through the effort to have conversations and looking to deeper and evaluate that may make sense.

所以我們正在進一步追求這些。目前我們不知道它們是否會取得成果，但有一些重大興趣，我們正在努力進行對話，尋求更深入的了解和評估可能有意義的事情。

To the extent that we get proceeds in, I think we'll evaluate the markets at the time and the other opportunities at the time on what is the best way to delever the company. My focus is clearly on delevering and balancing our capital structure, and we can do that in two ways. We can pay down debt, we can grow EBITDA.

就我們獲得的收益而言，我認為我們將評估當時的市場和當時的其他機會，以確定公司去槓桿化的最佳方式。我的重點顯然是去槓桿化和平衡我們的資本結構，我們可以透過兩種方式做到這一點。我們可以償還債務，我們可以增加 EBITDA。

And if we have the right opportunity for acquisition at the time we have cash in hand, and we think that that could be more accretive, that's something we would certainly take a look at. If the markets are such that debt paydown is the better play, I think we'd take a look at that. So I know I'm not giving you a specific answer here, but we'll evaluate based on the timing that the cash comes in, what we think is the best way to delever.

如果我們在手頭上有現金的時候有合適的收購機會，並且我們認為這可能會帶來更大的增值，那麼我們肯定會考慮這一點。如果市場認為償還債務是更好的選擇，我認為我們會考慮一下。所以我知道我不會在這裡給你一個具體的答案，但我們會根據現金到來的時間來評估我們認為最好的去槓桿化方式。

Stephen Baxter, Wells Fargo.

史蒂芬‧巴克斯特，富國銀行。

Hey, thanks for the question. Another one on payer mix. I might have thought that with the growth of the exchanges or maybe potentially some catch-up in the commercial demand that you were hoping to see in 2023 that there could potentially be upside risk to payer mix. It sounds like you're a bit more cautious there. I just want to make sure we really are capturing all the dynamics that you want us to keep in mind.

嘿，謝謝你的提問。另一個關於付款人組合的問題。我可能認為，隨著交易所的成長，或者您希望在 2023 年看到的商業需求的潛在追趕，支付者組合可能存在上行風險。聽起來你在那裡比較謹慎。我只是想確保我們確實捕捉到了您希望我們牢記的所有動態。

And then just to come back to AR briefly, just to manage our expectations, would we expect to see progress as soon as the first quarter. Like are you actually seeing or now improve to date this year? Or should we be thinking about maybe a more gradual progression throughout the balance of the year? Thank you.

然後簡單地回到 AR 上來，為了管理我們的預期，我們希望盡快在第一季看到進展。今年到目前為止，您是否真正看到或現在有所改善？或者我們應該考慮在今年餘下的時間裡採取更漸進的進展？謝謝。

Sure. A couple of things I'll mention on payer mix, and Tim, feel free to jump in as well. So we did grow both commercial and Medicare population payer mix in the fourth quarter. So I want to be very clear, we grew both. But the MA business outpaced the commercial business by about 2 to 1 in the fourth quarter.

當然。我會提到一些關於付款人組合的事情，提姆也請隨意加入。因此，我們在第四季度確實增加了商業和醫療保險人口的支付結構。所以我想說得很清楚，我們都成長了。但第四季 MA 業務的成長速度超過商業業務，成長率約 2 比 1。

For the full year, it outpaced the commercial 3 to 1. So we did make improve -- that proportional change was better in the fourth quarter than for the full year, but MA did outpace the growth. So as we go into '24, we look for some moderation of that, but we're still cognizant of keeping our eye on that payer mix dynamic.

全年的表現以 3 比 1 的比例超越了商業廣告。所以我們確實做出了改進——第四季度的比例變化比全年更好，但 MA 確實超過了增長。因此，當我們進入 24 世紀時，我們會尋求一些適度的調整，但我們仍然意識到要密切關注付款人組合的動態。

There's one other on AR.

AR 上還有另外一個。

On AR, sorry, I forgot the second part of that question. On AR, I think we'll see some early benefits in '24 as it relates to the buildup in AR from like the Mississippi supplemental program that will largely be collected in Q1. Some of the other buildup will probably be more moderate throughout the year. But I do expect over the course of the year for us to make improvements and to recapture the remainder of the conversion AR plus the buildup on AR from some of the movement to MA, more commercial payers slowing down that should moderate throughout 2024, and over the course of the year, I expect an improvement.

關於 AR，抱歉，我忘記了該問題的第二部分。在 AR 方面，我認為我們將在 24 年看到一些早期的好處，因為它與 AR 的積累有關，例如密西西比補充計劃，該計劃將主要在第一季度收集。其他一些增長全年可能會較為溫和。但我確實希望在這一年中，我們能夠做出改進，重新奪回AR 轉換的剩餘部分，加上AR 的積累，因為一些向MA 的轉移導致AR 的積累，更多商業支付者的放緩應該會在2024 年期間放緩，並且超過在這一年的過程中，我期望有所改善。

Josh Raskin, Nephron Research.

喬許·拉斯金，腎單位研究。

Hey, good morning. This is actually Marco on for Josh. Appreciate you taking the question.

嗨，早安。這其實是馬可為喬希代言。感謝您提出問題。

Just looking at the 2024 guidance, just wondering if you could parse out some of the $350 million to $400 million in CapEx for 2024. Is that mainly maintenance CapEx at this point, or do you have any other notable projects in the pipeline that are coming through this year? And do you have any ability to flex that lower in 2024 if you need to? Thanks.

只要看看 2024 年的指導，只是想知道您是否可以解析 2024 年 3.5 億至 4 億美元的資本支出中的一部分。目前主要是維護資本支出，還是今年還有其他值得注意的項目正在進行中？如果需要的話，您是否有能力在 2024 年降低這一比例？謝謝。

Sure. So we have been running approximately 50% maintenance capital, 50% growth capital over the last several years if you go back and look at our CapEx. And I would say, proportionately, that's still very similar in 2024, will be split about 50:50. As I mentioned, a couple of the large projects that are high-cost projects, the inpatient having patient towers and adding beds, are winding down in 2024. And then with fewer hospitals as we actually sold eight hospitals in 2023, that lowers some of our maintenance capital as well related to those. So overall, I don't think we are materially decreasing the amount of maintenance or growth capital comparatively.

當然。因此，如果你回頭看看我們的資本支出，過去幾年我們一直在運作約 50% 的維護資本和 50% 的成長資本。我想說，按比例來說，到 2024 年仍然非常相似，比例大約是 50:50。正如我所提到的，一些高成本的大型計畫（例如住院大樓和增加床位的住院計畫）將於 2024 年逐步結束。然後，隨著醫院數量的減少，我們實際上在 2023 年出售了 8 家醫院，這也降低了我們與這些相關的一些維護資本。因此，總的來說，我認為我們相對而言並沒有實質地減少維護或成長資本的數量。

The other thing is we've had some capital related to Project Empower over the last year. The majority of what we'll be spending in 2024 will be more on the expense side as now the systems and so forth for that project are built, and the costs going forward are going to be implementation and training and rollout costs. So there's some reduction there as well.

另一件事是我們去年獲得了一些與 Project Empower 相關的資金。2024 年我們的大部分支出將更多地用於支出方面，因為現在該項目的系統等已經建成，未來的成本將是實施、培訓和推出成本。所以那裡也有一些減少。

The only thing I would add to your question is if you could you throttle that back. Anything is certainly possible, but no similar to what we did in 2023, we were very deliberate in our investments into the core business with the intention of, as Kevin said earlier, working on projects that will help us certainly drive stronger EBITDA performance, which is a benefit to the long-term value of the company and its shareholders.

我對你的問題唯一要補充的是你是否可以限制它。一切皆有可能，但與我們在2023 年所做的不同，我們對核心業務的投資非常慎重，目的是，正如凱文早些時候所說，致力於開發能夠幫助我們推動更強勁EBITDA 業績的項目，這有利於公司及其股東的長期價值。

So a similar equation obviously comes into play in 2024. We have a strong pipeline of projects. As I said, previously, a lot of those are on the ambulatory side of the business, not as many high dollar inpatient investments that we're making in 2024. So I think it just is a normal settling of the capital spend, but we're very, very deliberate in how we're allocating our cash in that regard.

因此，類似的方程式顯然會在 2024 年發揮作用。我們擁有強大的專案儲備。正如我之前所說，其中許多都是流動業務，而不是我們在 2024 年進行的高額住院投資。因此，我認為這只是資本支出的正常結算，但我們在如何分配這方面的現金方面非常非常慎重。

Great. Thanks for the color. And then if I could squeeze in one follow-up. You spoke to about $1 billion in potential proceeds from divestiture opportunities that you now have identified. And can you help us understand a little bit more about the cadence of how that could ultimately be realized, especially in light of some of the FTC scrutiny that we've seen over some of these deals more recently? And then, is there any financial detail you can provide around the revenue or EBITDA contribution of those assets? Thank you.

偉大的。謝謝你的顏色。然後我是否可以擠出一個後續行動。您談到了您現在已經確定的剝離機會帶來的約 10 億美元的潛在收益。您能否幫助我們更多地了解最終實現這一目標的節奏，特別是考慮到我們最近看到的聯邦貿易委員會對其中一些交易的一些審查？然後，您是否可以提供有關這些資產的收入或 EBITDA 貢獻的任何財務細節？謝謝。

Sure. I think it's probably too early to tell or to say much. We don't have any group agreements signed at this point, but this is inbound interest that we're evaluating. I would say, generally speaking, all of these deals would be in that 10 times plus multiple of trailing EBITDA if they're to come to fruition.

當然。我認為現在說或說太多可能還為時過早。目前我們還沒有簽署任何集團協議，但這是我們正在評估的入境興趣。我想說，一般來說，所有這些交易如果要實現的話，其金額將是往期 EBITDA 的 10 倍以上。

Again, we've not made a decision, and we've not fully negotiated on any of these deals. But we do have inbound interest that it's very reasonable to think that if we decide to move forward, we could get deals done.

再說一次，我們還沒有做出決定，也沒有就這些交易進行充分談判。但我們確實有興趣，我們有理由認為，如果我們決定繼續前進，我們就可以完成交易。

That said, deals don't move very quickly. As you're well aware, I would expect the earliest is something to be completed and would be probably midyear. And then the potential for others to be completed late year early next year.

也就是說，交易進展不會很快。正如您所知道的，我預計最早的工作可能會在年中完成。然後其他人有可能在年底明年初完成。

Thank you. This concludes our question-and-answer session. I would now like to turn the call back over to Mr. Hingtgen for any closing remarks.

謝謝。我們的問答環節到此結束。我現在想將電話轉回給興特根先生，請他發表結束語。

Thank you, MJ, and thanks to all of you for joining our call today. We look forward to providing you with updates on our progress throughout 2024 and to demonstrate that our strategies and initiatives are producing positive momentum and results. As always, if you have additional questions, you can reach us at 615-465-7000. Thanks again and have a great day.

謝謝你，MJ，也謝謝大家今天加入我們的電話會議。我們期待向您提供 2024 年全年進展的最新信息，並證明我們的策略和舉措正在產生積極的勢頭和成果。與往常一樣，如果您還有其他問題，請致電 615-465-7000 與我們聯絡。再次感謝，祝您有美好的一天。

The conference has now concluded. Thank you for attending today's presentation. You may now disconnect.

會議現已結束。感謝您參加今天的演講。您現在可以斷開連線。