Community Health Systems Inc (CYH) 2024 Q3 法說會逐字稿

Good day, and welcome to the Community Health Systems third-quarter 2024 earnings conference call. (Operator Instructions) Please note this event is being recorded. I would now like to turn the conference over to Anton Hie, Vice President of Investor Relations. Please go ahead.

美好的一天，歡迎參加社區健康系統 2024 年第三季財報電話會議。（操作員說明）請注意此事件正在被記錄。我現在想將會議交給投資者關係副總裁 Anton Hie。請繼續。

Thank you, Dave. Good morning, and welcome to Community Health Systems' third-quarter 2024 conference call. Participating on today's call are Tim Hingtgen, Chief Executive Officer; Kevin Hammons, President and Chief Financial Officer; and Dr. Miguel Benet, Executive Vice President, Clinical Operations.

謝謝你，戴夫。早上好，歡迎參加社區健康系統 2024 年第三季電話會議。執行長 Tim Hingtgen 出席了今天的電話會議；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 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 interest Risk Factors in our annual report on Form 10-K and other reports filed with or furnished to the SEC.

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。這些前瞻性陳述面臨許多已知和未知的風險，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的「利益風險因素」標題中進行了描述。

Actual results may differ significantly from those expressed in any forward-looking statements in today's discussion. We do not intend to update any of these forward-looking statements. Yesterday afternoon, we issued a press release with our financial statements and definitions and calculations of adjusted EBITDA and adjusted EPS. We've also posted a supplemental slide presentation on our website.

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。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。

All calculations we will discuss exclude impairment expense as well as gains or losses on the sale of businesses, expense from government and other legal matters and related costs, expense from business transformation costs, expense related to employee termination benefits and other restructuring charges and change in estimate for professional claims liability.

我們將討論的所有計算均不包括減損費用以及出售業務的損益、政府和其他法律事務及相關成本的費用、業務轉型成本的費用、與員工解僱福利相關的費用和其他重組費用以及變化專業索賠責任的估計。

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, and thanks, everyone, for joining our third quarter earnings conference call. I'd like to begin by addressing the impact of back-to-back hurricanes, Helene and Milton. The hurricanes impacted several of the communities we serve, primarily in Florida, Georgia and East Tennessee.

謝謝安東，也謝謝大家參加我們的第三季財報電話會議。我想先談談連續颶風海倫和米爾頓的影響。颶風影響了我們服務的幾個社區，主要是佛羅裡達州、喬治亞州和田納西州東部。

As a result, in late third quarter and early fourth quarter, CHS hospitals most likely to experience severe impact, ramp-down services and canceled elective procedures. In total, three of our facilities were evacuated and closed consistent with local orders.

因此，在第三季末和第四季初，CHS 醫院最有可能遭受嚴重影響、服務減少和擇期手術取消。根據當地命令，我們總共疏散並關閉了三個設施。

The biggest impacts occurred in our ShorePoint Health System located south of Tampa, Physicians Regional Health care system in Naples and Tenova Newport in East Tennessee. Most significantly, ShorePoint Punta Gorda experienced major damage due to flooding. The hospital remains closed today and remediation efforts are currently underway.

受影響最大的是位於坦帕南部的 ShorePoint 衛生系統、那不勒斯的醫師區域衛生保健系統和田納西州東部的特諾瓦紐波特。最重要的是，ShorePoint Punta Gorda 因洪水遭受了嚴重破壞。該醫院今天仍然關閉，目前正在進行補救工作。

Hurricane readiness and response has proven to be a core competency at CHS, and I want to note that the effort to safely actuate patients was enabled by terrific coordination between our hospitals, our CHS transfer center operation and numerous other corporate resources that worked around the clock to be ready for Helene and then Milton.

事實證明，颶風準備和回應是 CHS 的核心能力，我想指出的是，安全救治患者的努力是透過我們的醫院、CHS 轉運中心運營和眾多其他全天候工作的企業資源之間的出色協調來實現的為海倫和米爾頓做好準備。

Our hearts go out to all affected by these terrible weather events. And I just want to mention that our CHS Cares Bond, which was established to help employees in need of financial assistance following an unforeseen disaster or situation has already been supporting hundreds of impacted team members.

我們的心與所有受到這些可怕天氣事件影響的人同在。我只想提一下，我們的 CHS 關懷債券是為了幫助在發生不可預見的災難或情況後需要經濟援助的員工而設立的，它已經為數百名受影響的團隊成員提供了支持。

Kevin will talk more about the financial impact of the hurricane on the third quarter results in just a moment. Despite the late quarter hurricane impact, same-store volumes improved with a 2.4% increase in admissions and a 2.6% increase in adjusted admissions over the prior year quarter. Surgeries improved 3.1%, led by growth in lower acuity outpatient cases driven by our consistent investments into ambulatory surgery sites of care.

凱文稍後將詳細討論颶風對第三季業績的財務影響。儘管受到季度末颶風的影響，同店銷量仍有所改善，與去年同期相比，入場人數增長了 2.4%，調整後入場人數增長了 2.6%。手術改善了 3.1%，這主要是由於我們對門診手術護理場所的持續投資推動了低視力門診病例的成長。

While patient demand for services was good overall, inpatient acuity skewed lower-than-expected effect net revenue which totaled $3.09 billion in the quarter. Adjusted EBITDA was $347 million. Our third quarter results were impacted by a continued increase in denials and downgrades by insurers. We are seeing some payers aggressively deny payment for medically necessary services that have been provided for our patients.

雖然患者對服務的需求總體良好，但住院患者的病情嚴重程度導致淨收入低於預期，該季度淨收入總計 30.9 億美元。調整後 EBITDA 為 3.47 億美元。我們第三季的業績受到保險公司拒絕和降級持續增加的影響。我們看到一些付款人積極拒絕支付為我們的患者提供的醫療必要服務的費用。

For several quarters now, the challenges we and our industry are facing regarding increasing denial activity by payers has been well documented. And over the last few years, and in response to this challenge, we have stood up an enhanced utilization review program and centralized physician adviser services to ensure our patients are placed in the correct care status and that we receive the appropriate payment for their care. As a result, our Physician Adviser Service has been able to obtain a high rate of reversal on initial payer denials.

幾個季度以來，我們和我們的行業在付款人拒絕增加的活動方面所面臨的挑戰已被充分記錄。在過去的幾年裡，為了應對這項挑戰，我們建立了強化的利用審查計劃和集中的醫生顧問服務，以確保我們的患者處於正確的護理狀態，並確保我們獲得適當的護理費用。因此，我們的醫師顧問服務能夠在最初付款人拒絕的情況下獲得很高的撤銷率。

Nevertheless, the rate of denial activity by payers continues to grow and have continued to pressure our top line. We are making incremental investments in our centralized patient financial services processes and team as well as our physician adviser program to continue to advocate for the appropriate classification of care for our patients and payment for the services our health systems provide.

儘管如此，付款人的拒絕行為繼續增加，並繼續給我們的收入帶來壓力。我們正在對集中的患者財務服務流程和團隊以及醫生顧問計劃進行增量投資，以繼續倡導對患者進行適當的護理分類並為我們的衛生系統提供的服務付費。

While the quarter did not fully meet all of our expectations, I remain very proud of our team's ability to face unexpected challenges head on, and I am optimistic about our opportunities. We expect normal seasonality improvements in the fourth quarter, and we remain optimistic that our focus on adding incremental inpatient capacity, outpatient access points and recruitment of specialists necessary to grow higher acuity service lines will position our health systems for growth into 2025 and beyond.

雖然本季沒有完全滿足我們的所有期望，但我仍然為我們團隊直面意外挑戰的能力感到非常自豪，並且我對我們的機會感到樂觀。我們預計第四季度會出現正常的季節性改善，我們仍然樂觀地認為，我們的重點是增加住院容量、門診就診點以及招募必要的專家以發展更高的敏銳度服務線，這將使我們的衛生系統在2025 年及以後實現成長。

We have been delivering upon our strategic growth plans across our health systems fueled by key capital investments. A few recent and notable investments include our Knoxville North Tower expansion, which opened earlier this year and is ramping up well. The new capacity was a catalyst for strong incremental patient volumes, posting a double-digit increase versus the same quarter last year. And this Saturday, we are opening a new patient tower and incremental surgical capacity in Baldwin County, Alabama.

在關鍵資本投資的推動下，我們一直在整個衛生系統中實現策略性成長計畫。最近的一些值得注意的投資包括我們的諾克斯維爾北塔擴建項目，該項目於今年早些時候開業，目前進展順利。新的產能是患者數量強勁成長的催化劑，與去年同期相比實現了兩位數的成長。本週六，我們將在阿拉巴馬州鮑德溫縣開設一座新的患者塔並增加手術能力。

These developments are core components of the nearly $200 million campus expansion taking shape there all of which will create capacity for incremental market share gains in this rapidly growing region. On the outpatient side, we now operate a total of 18 freestanding ED location following the opening of new centers in Huntsville, Alabama and Lake Granbury, Texas; we also completed the expansion of the hospital emergency department at Grandview Medical Center in Birmingham, Alabama.

這些開發案是正在實施的近 2 億美元園區擴建的核心組成部分，所有這些都將為在這個快速增長的地區增加市場份額創造能力。在門診方面，繼阿拉巴馬州亨茨維爾和德克薩斯州格蘭伯里湖開設新中心後，我們現在總共運營 18 個獨立急診室；我們也完成了阿拉巴馬州伯明罕 Grandview 醫療中心醫院急診科的擴建。

All of these projects have resulted in immediate volume growth. And we recently announced a definitive agreement to acquire Carbon Health's 10 urgent care locations in the Tucson, Arizona market. This will expand our urgent care footprint to 17 locations across that market.

所有這些項目都導致銷量立即增長。我們最近宣布了一項最終協議，收購 Carbon Health 在亞利桑那州圖森市場的 10 個緊急護理​​中心。這將使我們的緊急護理足跡擴展到該市場的 17 個地點。

We expect that transaction to close this quarter. My confidence in our strategic direction, health system leadership team and especially the women and men who provide care for our patients is at an all-time high. The services we provide are critically important to our patients and communities and our commitment to provide that care while also achieving strong operating and financial results is unwavering.

我們預計該交易將於本季完成。我對我們的策略方向、衛生系統領導團隊，尤其是為我們的患者提供護理的女性和男性的信心空前高漲。我們提供的服務對我們的患者和社區至關重要，我們堅定不移地致力於提供這種護理，同時實現強勁的營運和財務表現。

With that, Kevin, let me turn the call over to you.

凱文，讓我把電話轉給你。

Thank you, Tim, and good morning, everyone. Underlying demand for care in our markets remains strong, leading to the same-store volume growth, including a 2.4% increase in admissions and a 2.6% increase in adjusted admissions. Same-store ED visits were up 0.8% and surgeries were up 3.1%.

謝謝蒂姆，大家早安。我們市場對照護的潛在需求依然強勁，導致同店銷售成長，包括入院人數成長 2.4% 和調整後入院人數成長 2.6%。同店急診就診次數增加了 0.8%，手術次數增加了 3.1%。

As a result of Hurricane Helene, during the third quarter, one of our facilities was forced to evacuate patients and several facilities saw delays in scheduled electives. We estimate an approximate $7 million impact during the third quarter from missed revenue and incremental costs.

由於颶風海倫，在第三季度，我們的一個設施被迫疏散患者，並且一些設施的預定選修課程出現延誤。我們估計第三季收入損失和成本增量造成的影響約為 700 萬美元。

However, ShorePoint Health Punta Gorda remains closed due to the extensive damage suffered from both hurricanes and will continue to be a headwind throughout the fourth quarter as it will be closed for the remainder of the year. Net operating revenues for the quarter were $3.09 billion, up slightly year-over-year on a consolidated basis.

然而，由於兩次颶風造成的廣泛破壞，ShorePoint Health Punta Gorda 仍處於關閉狀態，並且在整個第四季度將繼續成為不利因素，因為它將在今年剩餘時間內關閉。該季度淨營業收入為 30.9 億美元，合併後較去年同期略有成長。

On a same-store basis, net revenue increased 5.1%, which remain consistent with our target for mid-single-digit growth for the year. The same-store top line growth was driven by the 2.6% increase in adjusted admissions along with 2.5% growth in net revenue per adjusted admission, which largely reflects improved rates and incremental reimbursement under state Medicaid programs, partly offset by lower acuity.

以同店計算，淨收入成長 5.1%，與我們今年中個位數成長的目標一致。同店收入增長是由調整後入院人數增長2.6% 以及每次調整入院淨收入增長2.5% 推動的，這在很大程度上反映了州醫療補助計劃下費率的提高和增量報銷，但部分被敏銳度的降低所抵消。

We were pleased to see solid volume growth, including growth in our commercial book. However, the service line mix of the business was less favorable than expected with overall case mix index down 60 basis points from prior year, reflecting declines in both the surgical mix and the surgical CMI.

我們很高興看到銷量的穩健成長，包括商業書籍的成長。然而，該業務的服務項目組合不如預期，整體病例組合指數較前一年下降 60 個基點，反映出手術組合和手術 CMI 均下降。

Adjusted EBITDA for the third quarter was $347 million compared with $360 million in the prior year period. Margin for the quarter was 11.2%, down from 11.7% in the prior year period. Contributing to the lower-than-expected EBITDA, we have continued to experience significant increases in initial denials and downgrades by managed care plans with more than half of the incidents coming in the Medicare Advantage globe.

第三季調整後 EBITDA 為 3.47 億美元，去年同期為 3.6 億美元。本季利潤率為 11.2%，低於去年同期的 11.7%。導致 EBITDA 低於預期的原因是，管理式醫療計劃的最初拒絕和降級事件持續大幅增加，其中超過一半的事件發生在 Medicare Advantage 全球範圍內。

While denial activity is not new, the tactics used by the payers have become more aggressive, and we have experienced an approximate doubling of denials in the quarter compared with the prior year, which is an increase above our expectations. This resulted in an approximate $10 million headwind for the quarter.

雖然拒絕活動並不新鮮，但付款人使用的策略變得更加激進，本季的拒絕數量與前一年相比大約增加了一倍，增幅超出了我們的預期。這給本季度帶來了大約 1000 萬美元的不利影響。

As Tim noted, we are taking action to help ensure that the care we are providing is properly classified and reimbursed including further expansion of our centralized physician adviser program, along with additional steps to mitigate increased denials in the future.

正如蒂姆所指出的那樣，我們正在採取行動，幫助確保我們提供的護理得到適當分類和報銷，包括進一步擴大我們的集中醫生顧問計劃，以及採取其他措施來減少未來拒絕增加的情況。

Moving to expense management. We were once again pleased with our performance on labor costs. Average hourly wage rate increased 3.9% year-over-year, consistent with our expectations for the full year. Contract labor spend was down 24% year-over-year and declined $4 million sequentially to $41 million in the third quarter, which was better than our expectations and reflected the continued progress made possible by our recruitment and retention efforts.

轉向費用管理。我們再次對勞動成本的表現感到滿意。平均時薪年增3.9%，與我們全年預期一致。第三季合約工支出年減 24%，季減 400 萬美元，至 4,100 萬美元，這好於我們的預期，反映了我們的招募和留任工作所取得的持續進展。

We continue to see a meaningful improvement in controlling supplies expense, which on a same-store basis was down 1.3% per adjusted admission in the third quarter. As we move more hospitals on to our new ERP, we are gaining additional insights we can leverage to improve efficiencies and reduce supply expense. Medical specialist fees increased $15 million or approximately 10% from the prior year period with notable pressure in anesthesia.

我們繼續看到控制供應費用的顯著改善，第三季調整後的同店入場費用下降了 1.3%。隨著我們讓更多的醫院轉向新的 ERP，我們獲得了更多的見解，可以利用這些見解來提高效率並降低供應成本。由於麻醉壓力顯著，醫療專家費用比去年同期增加了 1,500 萬美元，約 10%。

This was slightly higher than expected in the third quarter. But overall, we remain pleased with the progress of our hospital-based provider and sourcing initiatives. Since launching in August of 2023, the in-source platform has expanded significantly in coverage of ED and hospital programs and is only just beginning in anesthesia with the first large market coming online in the fourth quarter. We have an active pipeline of additional programs coming in-house in the coming months and many others under consideration.

這略高於第三季的預期。但總體而言，我們對醫院供應商和採購計畫的進展仍然感到滿意。自 2023 年 8 月推出以來，該內源平台已顯著擴大了急診室和醫院項目的覆蓋範圍，而麻醉領域才剛開始，第一個大型市場將於第四季度上線。我們在未來幾個月內將推出一系列積極的內部附加計劃，還有許多其他計劃正在考慮中。

During the quarter, we booked a $149 million increase to our professional claims liability accrual based on a review by our new actuary. This change in estimate considers the national trend of outsized verdicts and propensity for larger claim settlements that have been experienced more recently, which is broadly being referred to in the industry to social inflation and the exposure of adverse development in our outstanding claims if this environment persists. Although we've not been the subject of any recent nuclear verdicts, we have experienced increased settlement amounts over historical averages, including those in jurisdictions that have historically resisted this behavior.

根據新精算師的審查，本季我們的專業索賠責任應計額增加了 1.49 億美元。這項估計的變化考慮了最近經歷的超大判決和更大索賠和解傾向的全國趨勢，業內廣泛提到社會通貨膨脹以及如果這種環境持續下去，我們的未決索賠將面臨不利發展的風險。儘管我們最近沒有成為任何核裁決的對象，但我們的和解金額超過了歷史平均水平，包括那些歷來抵制這種行為的司法管轄區的和解金額。

Furthermore, the majority of this change in estimate relates to claim activity and development from previously divested hospitals and is therefore not reflective of our current run rate of new claim activity, which has been much lower as we have made material improvements in our safety and quality outcomes. In fact, our improvements in some cases are industry-leading, and I'll ask Dr. Miguel Benet to comment for just a minute on some of these most recent accomplishments. Dr. Benet?

此外，估計的大部分變化與之前剝離的醫院的索賠活動和發展有關，因此並不能反映我們當前新索賠活動的運行率，因為我們在安全和品質方面取得了實質性改進，所以新索賠活動的運行率要低得多結果。事實上，我們在某些​​情況下的改進是業界領先的，我將請 Miguel Benet 博士對其中一些最新成就發表評論。貝內特博士？

Thank you, Kevin. CHS has a long-standing commitment to advance clinical quality and patient safety, and that commitment is ingrained into our culture at every level of the organization.

謝謝你，凱文。CHS 長期致力於提高臨床品質和病人安全，這項承諾已根植於我們組織各個層面的文化中。

We're very proud of the many positive results that we are achieving, especially this year and we are confident that we can continuously improve quality and safety, producing better outcomes and higher value for our patients. CHS began monitoring our organization-wide serious safety event rate more than a decade ago. Significant improvements in this area have saved lives and saved thousands of patients from preventable harm.

我們對所取得的許多積極成果感到非常自豪，尤其是今年，我們相信我們能夠不斷提高品質和安全性，為患者帶來更好的結果和更高的價值。CHS 在十多年前就開始監測整個組織範圍內的嚴重安全事件發生率。這一領域的重大改進挽救了生命，並使數千名患者免受可預防的傷害。

That work continues. And I would like to highlight achievements in three specific areas, including: first, we've achieved a nearly 20% improvement in our risk-adjusted mortality index in the prior year period, which put CHS in the top quartile of all US hospitals. There are many initiatives that have led to this accomplishment including a company-wide focus on immediate treatment of patients with sepsis.

這項工作仍在繼續。我想強調在三個具體領域取得的成就，包括：首先，我們的風險調整死亡率指數比前一年提高了近 20%，這使 CHS 在美國所有醫院中名列前四分之一。這項成就的措施有很多，包括全公司範圍內對膿毒症患者立即治療的關注。

We've also achieved a nearly 24% improvement versus the same period last year and our patient safety and adverse event composite from CMS, which measures effectiveness in protecting patients from complications. The improvement places CHS in the top 5% of hospitals nationwide. And we're pleased to report a 27% year-over-year improvement in our precursor safety event rate, continuing our trend of reducing serious safety events almost every quarter since the baseline was established in 2012.

與去年同期相比，我們的患者安全和不良事件綜合數據也實現了近 24% 的改善，該綜合數據衡量了保護患者免受併發症影響的有效性。這項進步使 CHS 躋身全國前 5% 的醫院之列。我們很高興地報告，先兆安全事件發生率年增了 27%，延續了自 2012 年建立基準以來幾乎每季嚴重安全事件減少的趨勢。

Our data science program is maturing and providing insights to help identify areas like these, but we can optimize our clinical outcomes and deliver further improvements across the organization. Of course, it is the physicians, nurses and other caregivers who commit daily to providing high-quality care for their patients and make these accomplishments possible. We certainly appreciate your dedication to quality and safety.

我們的數據科學計劃正在成熟，並提供見解來幫助識別此類領域，但我們可以優化我們的臨床結果並在整個組織內提供進一步的改進。當然，正是醫生、護士和其他護理人員每天致力於為患者提供高品質的護理，並使這些成就成為可能。我們當然感謝您對品質和安全的奉獻。

With that, Kevin, I'll turn it back over to you.

這樣，凱文，我會把它轉回給你。

Thank you, Miguel. Back to our financial review. Cash flows from operations were $67 million for the third quarter of 2024 compared with $29 million in the year ago period. The year-over-year improvement in cash flow primarily reflects improved cash flow from changes in working capital, including conversion of accounts receivable as expected. Capital expenditures for the third quarter of 2024 were $70 million and for the year-to-date were $251 million, on track for our 2024 guidance range of $350 million to $400 million.

謝謝你，米格爾。回到我們的財務審查。2024 年第三季的營運現金流為 6,700 萬美元，而去年同期為 2,900 萬美元。現金流量較去年改善主要反映了營運資金變動帶來的現金流量改善，包括應收帳款按預期轉換。2024 年第三季的資本支出為 7,000 萬美元，今年迄今的資本支出為 2.51 億美元，預計將實現 2024 年 3.5 億美元至 4 億美元的指導範圍。

In August, we completed the divestiture of Tenova, Cleveland and used part of the proceeds to extinguish approximately $143 million of principal value of our 5% and 5/8% senior secured notes due 2027 and through open market repurchases, utilizing cash on it. We continue to make progress towards our $1 billion divestiture plan. We anticipate the majority of the remaining transactions to be complete -- to complete this plan will likely be signed in the fourth quarter, with final closings carrying over into the first quarter of 2025.

8 月，我們完成了對克利夫蘭特諾瓦(Tenova) 的剝離，並利用部分收益透過公開市場回購，用現金清償了2027 年到期的5% 和5/8% 高級擔保票據本金約1.43億美元。我們繼續在 10 億美元的剝離計劃方面取得進展。我們預計大部分剩餘交易將完成——完成該計劃可能會在第四季度簽署，最終交割將延續到 2025 年第一季。

At the end of the quarter, net debt to trailing adjusted EBITDA was 7.6 times, consistent with the prior quarter and improved from 7.9 times at year-end 2023. We continue to believe we have more than adequate liquidity to meet our needs going forward, with approximately $440 million of borrowing capacity under the ABL along with pending asset sale proceeds. Our implementation of a new ERP and workflows along with standardization of data under our Project in Power enters the final innings.

截至本季末，淨負債與追蹤調整後 EBITDA 比率為 7.6 倍，與上一季一致，較 2023 年底的 7.9 倍有所改善。我們仍然相信，我們擁有足夠的流動性來滿足未來的需求，ABL 下的借貸能力約為 4.4 億美元，加上待定的資產出售收益。我們實施新的 ERP 和工作流程以及 Power 專案下的資料標準化進入了最後階段。

As of October 1, we have all of our subsidiaries up and running on the new financial and supply chain platforms and transitioned into our shared service environment. We are on track to complete the implementation of the ERP by transitioning on to the new workforce management tools for HR, payroll and timekeeping, thus completing the bulk of the transition work in the first quarter of 2025. As we enter 2025, we will benefit by having the investment and disruption behind us, and we can focus on optimizing our use of the new tools and benefit realization.

截至 10 月 1 日，我們所有子公司均在新的金融和供應鏈平台上啟動並運行，並過渡到我們的共享服務環境。我們預計將透過過渡到新的人力資源、薪資和考勤勞動力管理工具來完成 ERP 的實施，從而在 2025 年第一季完成大部分過渡工作。進入 2025 年，我們將受益於背後的投資和顛覆，我們可以專注於優化新工具的使用和效益實現。

With one quarter remaining in 2024, we are adjusting our guidance range as we continue to assess the impact of Hurricane Helene and Milton on our operations. Specifically, we now anticipate 2024 adjusted EBITDA of $1.5 billion to $1.54 billion, which consistent with prior guidance, does not include any contribution from potential new supplemental payment programs nor does it assume any future divestiture activity.

距離 2024 年還剩四分之一，我們正在調整指導範圍，同時繼續評估颶風海倫和米爾頓對我們營運的影響。具體來說，我們現在預計 2024 年調整後 EBITDA 為 15 億美元至 15.4 億美元，這與先前的指導一致，不包括潛在的新補充付款計劃的任何貢獻，也不假設未來有任何剝離活動。

While not yet providing formal guidance for 2025, in response to repeated investor inquiries and in the interest of transparency, we are providing an initial estimate of the potential benefit from the new or expanded state Brexit payment programs in New Mexico and Tennessee. Both programs have been approved by the respective legislatures and governors and submitted to CMS, where they are currently awaiting approval.

雖然尚未提供 2025 年的正式指導，但為了回應投資者的反覆詢問並出於透明度考慮，我們正在對新墨西哥州和田納西州新的或擴大的州脫歐支付計劃的潛在收益進行初步估計。這兩個計劃都已獲得各自立法機構和州長的批准，並已提交給 CMS，目前正在等待批准。

At this time, based on our interpretation of the programs is designed and the various puts and takes, we estimate an aggregate EBITDA benefit of approximately $100 million to $120 million annually. This concludes our prepared remarks. So at this time, we'll turn the call back over to the operator for Q&A.

目前，根據我們對計畫設計的解釋以及各種投入和投入，我們估計每年的 EBITDA 總收益約為 1 億至 1.2 億美元。我們準備好的演講到此結束。所以這時候我們會把電話轉回給接線生進行問答。

(Operator Instructions)

（操作員說明）

Brian Tanquilut, Jefferies.

布萊恩·坦奎魯特，傑弗里斯。

Hey, good morning, guys. Maybe, Kevin, I'll touch on that last comment you made just on the DPP. So $100 million to $120 million, this is just for New Mexico and Tennessee. And then is this net of provider taxes just to clarify that?

嘿，早上好，夥計們。凱文，也許我會談談你剛剛對民進黨發表的最後評論。1 億到 1.2 億美元，這只是新墨西哥州和田納西州的情況。那麼扣除提供者稅後的淨額只是為了澄清這一點嗎？

Yes. That is the aggregate amount from both Tennessee and New Mexico on an annual basis and is the net EBITDA benefit. So that would be net of the provider taxes. So there would be a gross-up impact on net revenue and then additional expense. It is also net of what we may see in terms of sunsetting some existing reimbursement benefit and maybe some additional cost that we could incur as a result of these plans being approved as we've seen in the past and some other state.

是的。這是田納西州和新墨西哥州每年的總金額，也是 EBITDA 淨收益。所以這將扣除提供者稅。因此，會對淨收入和額外費用產生整體影響。這還不包括我們可能會看到的一些現有報銷福利的取消，以及由於這些計劃獲得批准而可能產生的一些額外成本，正如我們在過去和其他一些州所看到的那樣。

So that is what our current estimate is of our EBITDA benefit on an annual basis. I would remind everyone that if those are approved in the fourth quarter, as we expect, they will be. Those plans are retroactive back to July 1, 2024, so we could potentially get 6 months' worth of that, again, if CMS approved them during the fourth quarter.

這就是我們目前對每年 EBITDA 效益的估計。我想提醒大家，如果這些計劃如我們預期的那樣在第四季度獲得批准，那麼它們就會獲得批准。這些計劃可追溯至 2024 年 7 月 1 日，因此，如果 CMS 在第四季度批准這些計劃，我們可能會再次獲得 6 個月的計劃。

Understand. And then maybe, Kevin, as I think about your EBITDA guidance change and the free cash flow guidance change, maybe if you can bridge me from that $40 million cut to EBITDA to the 100-plus -- or $100 million cut to free cash flow, just curious.

理解。然後，凱文，當我考慮您的 EBITDA 指導變更和自由現金流指導變更時，也許您可以將我從 EBITDA 削減 4000 萬美元過渡到自由現金流削減 100 多 - 或 1 億美元，只是好奇。

Sure. There's a couple of other things that I'd point out. So obviously, a big one there is the reduction in EBITDA. The denials and truly the slowdown in the adjudication process is also having an impact on our cash collections. A number of the claims that have been denied are still not through the final adjudication process, and that seems to be continually slowing down. So we've taken that into consideration.

當然。我還想指出一些其他的事情。顯然，其中一個重要因素就是 EBITDA 的減少。否認和裁決過程的放緩也對我們的現金收集產生了影響。一些被駁回的索賠尚未通過最終裁決程序，而且這一進程似乎正在不斷放緩。所以我們考慮到了這一點。

There is a small amount of some state program monies that we, as stock, might get approved in the third quarter that will be approved in the fourth quarter, but the cash for those will likely slip into the first quarter of 2025. So that's just a matter of timing. And then with one of the divestitures in Pennsylvania that we have announced that we expect to close in the fourth quarter, we are selling working capital with that. So net working capital get pulled out in the anticipated collections related to those receivables won't be in the fourth quarter.

我們作為股票可能會在第三季獲得少量的一些國家計劃資金，這些資金將在第四季度獲得批准，但這些資金可能會滑入 2025 年第一季。所以這只是時間問題。然後，我們宣布預計將在第四季度完成賓州的一項資產剝離，我們將以此出售營運資金。因此，與這些應收帳款相關的預期收款不會在第四季度提取淨營運資本。

I got it. Thank you.

我得到了它。謝謝。

A.J. Rice, UBS.

A.J.賴斯，瑞銀。

Thanks. Hi, everybody. Just to go back to that guidance change on the EBITDA. So a reduction of about $40 million at the midpoint. I think $18 million of that is in third quarter variance, hurricane and otherwise. So that leaves about $22 million for the fourth quarter, if I've got the numbers right. You've got, I'm sure, additional hurricane impact given the timing of the second hurricane.

謝謝。大家好。回到 EBITDA 的指導變化。因此，中間減少了約 4000 萬美元。我認為其中 1800 萬美元是由於第三季的差異、颶風和其他原因造成的。如果我的數字正確的話，那麼第四季剩下大約 2200 萬美元。我確信，考慮到第二次颶風的時間，你會受到額外的颶風影響。

You probably -- I don't know whether there's a change in your accruals for liability based on the update charge in the third quarter, but is that part of the dynamic? And then are you making any operational changes in your assumption for the fourth quarter?

您可能 - 我不知道根據第三季的更新費用，您的應計責任是否發生變化，但這是否是動態的一部分？那麼您對第四季的假設是否有任何營運變化？

Thanks, A.J. So I think your math there is right. About $18 million of the $40 million change at the midpoint is the quick to the miss in Q3. Then I would say the remainder is really split between the fourth quarter hurricane impact with Punagorda being shut down for the entire quarter as well as the disruption we had when Milton hit early in the quarter, there's certainly some EBITDA or some EV business that we won't get back from those days.

謝謝，A.J.所以我認為你的數學是正確的。中點 4000 萬美元的變化中，大約有 1800 萬美元是第三季最容易錯過的。然後我想說的是，剩下的部分實際上是由第四季度颶風影響（普納戈達整個季度關閉）以及米爾頓在本季度初遭受的破壞所造成的，當然我們贏得了一些EBITDA 或有些電動車生意回不去那些日子。

Hopefully, we'll recover some of the elective surgeries. There really is no operational changes being made. In terms of the MedMal expense, our increased liability really does not impact our go-forward run rate materially. We had already been increasing the run rate of expense. So that's kind of been baked in, and this adjustment really was going back and looking at the base claim amounts.

希望我們能夠恢復一些選擇性手術。實際上沒有進行任何操作更改。就 MedMal 費用而言，我們增加的負債實際上並沒有對我們的前進運行率產生重大影響。我們已經在提高費用運行率。所以這已經被考慮在內了，這次調整實際上是回顧基本索賠金額。

But in terms of run rate, we don't see that having a big impact. I do also want to point out relative to our guidance change on net revenue. We did bring down net revenue of $100 million at the midpoint. And that's largely due to reflecting the announced divestitures in Commonwealth and North Carolina, the one small hospital in North Carolina and taking the fourth quarter revenue down because we expect those to be complete deals to close here during the quarter. And then a smaller portion of that net revenue adjustment was again the hurricanes and denials.

但就運行率而言，我們認為這不會產生太大影響。我還想指出相對於我們對淨收入的指導變化。我們確實在中點減少了 1 億美元的淨收入。這主要是由於聯邦醫院和北卡羅來納州宣布的資產剝離（北卡羅來納州的一家小醫院）導致第四季度收入下降，因為我們預計這些交易將在本季度完成。然後，淨收入調整的一小部分又是颶風和否認。

Okay. That makes sense. Maybe just my follow-up question on those denials you're seeing, you said it's mainly concentrated in Medicare Advantage plans. When you drill down, is this mostly related to the change associated with the two midnight rules, that MA plans are having absorbed and that's creating confusion or is there other areas of focus on these denials that are being implemented.

好的。這是有道理的。也許只是我對您所看到的拒絕的後續問題，您說這主要集中在 Medicare Advantage 計劃中。當你深入研究時，這是否主要與與兩條午夜規則相關的變化有關，MA計劃正在吸收這些規則，這造成了混亂，或者是否有其他領域關注正在實施的這些否認。

How I would describe that is I think maybe the two-midnight rule is the impetus, but we're just seeing the payers be more aggressive across many areas of denials. So they're expanding the population of the claims, in which they're denied, and we're seeing it, again, the majority of it is in the MA book, but we're seeing more denials in the commercial book as well. So that's where we're seeing the impact above the prior trend and above what we hadn't previously anticipated.

我的描述是，我認為午夜兩點規則可能是推動力，但我們只是看到付款人在許多拒絕付款的領域變得更加激進。因此，他們正在擴大索賠的數量，在這些索賠中，他們被否認了，我們再次看到，其中大部分都在 MA 書中，但我們在商業書中也看到了更多的否認。因此，我們看到的影響超出了先前的趨勢，也超出了我們先前的預期。

Okay. Thanks a lot.

好的。多謝。

Andrew Mok, Barclays.

安德魯·莫克，巴克萊銀行。

Hi, good morning. Just wanted to follow up on this denied claims headwind. One, when did that start to materialize as a headwind in the quarter? And two, what can you do to combat this going forward? Do you have a stronger appeals case for these newer denials than what you would typically have? Thanks.

嗨，早安。只是想跟進這項被拒絕的索賠逆風。第一，這種情況什麼時候開始成為本季的不利因素？第二，你可以採取什麼措施來應對這種情況？對於這些新的拒絕，您是否有比平常更強的上訴理由？謝謝。

I think it was really can throughout the quarter. They've continued to ramp up. And really, it's the slowdown of the adjudication process that continues to kind of expand and we're -- as noted by our adjustment in our guidance in the fourth quarter, at this point, we're expecting that to continue to be a problem somewhat going forward as well.

我認為整個季度確實可以。他們繼續增加。事實上，裁決過程的放緩仍在繼續擴大，正如我們在第四季度的指導調整中所指出的那樣，在這一點上，我們預計這將繼續成為一個問題也有一些前進。

So I can't say that there wasn't one event during the quarter that would have pointed to, hey, this is changing, but we just continue to see a slow ramp-up in denials as well as the time frame for adjudication process. We have been successful in about 25% of the cases that have been denied and these are -- we're looking at cases greater than two midnights that have been denied.

因此，我不能說本季度沒有任何事件表明，嘿，這種情況正在發生變化，但我們只是繼續看到否認的緩慢增加以及裁決過程的時間框架。我們在大約 25% 的被拒絕案件中取得了成功，我們正在研究超過午夜兩點被拒絕的案件。

We've been successful in about 25% of those, getting those paid as an inpatient, but there still remains a material amount, almost 70% of those initial denials from claims this year that are no longer considered still (inaudible) or still in the process of not been finally -- final adjudicated.

我們已經成功處理了其中大約25% 的案件，讓這些人作為住院患者獲得了付款，但仍然有大量的資金，今年最初被拒絕的索賠中，幾乎70% 不再被視為仍然（聽不清）或仍處於等待狀態。

Yeah. Andrew, this is Tim. I'll add on to that. We have been experiencing increased denials throughout the year that most of that pain activity is coming out of the prior year because there's quite a tail on the actual denial appeal process. So what we saw in this quarter was an acceleration off of the run rate that we had in the first and second quarter, and that's the $10 million delta Kevin called out, it was -- that's the incremental increase that we did not expect a bounce in the third quarter.

是的。安德魯，這是提姆。我會補充這一點。我們全年都經歷了越來越多的否認，大部分痛苦活動來自前一年，因為實際的拒絕上訴過程有相當多的尾巴。因此，我們在本季度看到的是，我們在第一季和第二季的運行率有所加速，這就是凱文所說的1000 萬美元的增量，這是我們沒有預料到的反彈的增量成長在第三季。

Got it. And if I could just follow up. Is this broad-based activity across most of your payers? Is this more concentrated among a few?

知道了。如果我能跟進的話。您的大多數付款人是否都進行了這種基礎廣泛的活動？這是否更集中在少數人身上？

It's relatively broad-based.

它的基礎相對廣泛。

Yeah, I would agree.

是的，我同意。

And maybe to your other question about things that we're changing or can do going forward. we do now are in a position to have physician adviser coverage across our entire portfolio as well as having a more robust kind of appeals capabilities to go after some of these initial denials.

也許還有你關於我們正在改變或未來可以做的事情的其他問題。我們現在確實能夠在整個投資組合中擁有醫生顧問的覆蓋範圍，並擁有更強大的上訴能力來追蹤其中一些最初的拒絕。

Great. Thanks for the call.

偉大的。感謝您的來電。

Ben Hendrix, RBC.

本‧亨德里克斯，加拿大皇家銀行。

Thank you very much. Just a follow-up on the $22 million of the EBITDA guidance that you expect in the fourth quarter. Is it possible to parse that out between the impact from Puntagorta and the other hospitals versus claim denials. Just trying to get an idea of if those claim denials are expected to continue to accelerate into fourth quarter? Then if there's any impact on acuity in that number from the outpatient acuity, if there's just -- if you can just parse out kind of the impact within that $22 million.

非常感謝。這只是您預計第四季度 2200 萬美元 EBITDA 指導的後續行動。是否可以在蓬塔戈塔和其他醫院的影響與索賠被拒絕之間進行分析。只是想知道這些索賠被拒絕的情況是否預計會繼續加速到第四季？那麼，門診患者的視力是否對這個數字有任何影響，如果你能解析出這 2,200 萬美元中的影響。

Yeah. I would say more than half of that $22 million is hurricane impact. I would say the denial impact would look similar to Q3. And then the remainder being hurricane impact.

是的。我想說，這 2,200 萬美元中有一半以上是颶風造成的影響。我想說，拒絕的影響看起來與第三季類似。然後剩下的就是颶風的影響。

Thanks for that. Just a quick follow-up on the softer acuity. Can you talk to the -- or the drivers of that outpatient acuity softness? Is that just calendar related? We heard one of your peers talk about kind of forecast expectations for maybe some higher volume of lower acuity in the second half. I'm just wondering if you see that persisting through the rest of the year and then how that might look like for 2025. Thanks.

謝謝你。只是對軟敏銳度的快速跟進。您能談談門診敏銳度的柔軟度或驅動力嗎？這只是日曆相關嗎？我們聽到您的一位同行談論了對下半年可能出現的更高數量的較低敏銳度的預測期望。我只是想知道這種情況是否會持續到今年剩餘時間，以及 2025 年會是什麼樣子。謝謝。

Hey, Ben, this is Tim. I'll start it off and invite Kevin and Miguel to chime in. Just to clarify, the softness in the acuity that we called out was on the inpatient surgery side of the business. We had good, strong surgical growth in the quarter, as we pointed out earlier in our remarks, but that was primarily on the outpatient side of the business. We did see growth in inpatient surgery, but they were in the lower acuity inpatient surgery category.

嘿，本，這是蒂姆。我會先邀請凱文和米格爾插話。需要澄清的是，我們所說的敏銳度的軟弱是在住院手術方面。正如我們早些時候在評論中指出的那樣，本季度我們的手術成長良好且強勁，但這主要是在門診業務方面。我們確實看到住院手術的增長，但它們屬於視力較低的住院手術類別。

I think impacting that inpatient surgical acuity was just some continued site of care migration of our total joints to the outpatient side the last year. In the previous quarters, we had more inpatient total joints. We see more of that migrating into the ambulatory surgery environment. And just to clarify, we believe we're capturing that within our ambulatory surgery environment.

我認為影響住院患者手術敏銳度的只是去年我們的總關節向門診側遷移的一些持續護理部位。在前幾個季度，我們有更多的住院總關節患者。我們看到更多的這種情況遷移到門診手術環境。澄清一下，我們相信我們正在門診手術環境中捕捉到這一點。

We did a large expansion in one of our orthopedic focused [data] in Indiana, that is really ramping up very nicely. So that does have an impact on the surgical acuity. We did see softer inpatient surgery volumes on elective spine cases. We saw some softness on the CVT and Vascular services. Those are the areas where we believe we'll pick those back up in the fourth quarter with focused efforts of getting those patients back in for their care.

我們在印第安納州對一項以骨科為重點的[數據]進行了大規模擴展，這確實進展得非常好。所以這確實對手術敏銳度有影響。我們確實看到選擇性脊椎病例的住院手術量減少。我們看到 CVT 和血管服務有些疲軟。我們相信我們將在第四季度恢復這些領域，並專注於讓這些患者重新獲得護理。

Just to point out, our clinic visits in the third quarter, we always say that's a decent bellwether of what we can expect for volumes down the road. We did have really strong clinic business even factoring in the hurricane impact market. So we have no reason to believe that demand is just a softening overall. We believe it's more of a timing issue.

需要指出的是，我們在第三季的診所就診，我們總是說這是我們對未來銷售預期的一個不錯的風向標。即使考慮到颶風影響市場，我們的診所業務也確實非常強勁。因此，我們沒有理由相信需求只是整體疲軟。我們認為這更多的是一個時間問題。

Thank you.

謝謝。

Stephen Baxter, Wells Fargo.

史蒂芬‧巴克斯特，富國銀行。

Hi. Thanks. I know it's early for 2025 commentary, but just wanted to get your sense of how we should think about perhaps the 2024 revised guidance of the jump-off point because I guess, first, wondering like is it reasonable to expect essentially getting back all of the hurricane headwind, and you move into 2025? Or would you expect that there'd be any lingering disruption there?

你好。謝謝。我知道現在對 2025 年發表評論還為時過早，但只是想了解一下我們應該如何考慮 2024 年修訂後的起始點指南，因為我想，首先，想知道期望基本上收回所有內容是否合理？逆風，你進入2025 年了嗎？或者您認為那裡會有任何揮之不去的干擾嗎？

And then I guess, as we think about this incremental $10 million of denials, I assume obviously you're factoring in a bit similar for the fourth quarter. I guess what we also then have to consider as a headwind to maybe Q1 and Q2 before you lap that and maybe all these things are offsetting and this is a good jump-off point? Or should we think about it perhaps differently, let's get some insight there? Thanks.

然後我想，當我們考慮這 1000 萬美元的增量拒絕時，我認為顯然您正在考慮第四季度的情況。我想在你跑圈之前我們還必須考慮 Q1 和 Q2 的逆風，也許所有這些事情都在抵消，這是一個很好的起點？或者我們應該以不同的方式思考這個問題，讓我們從中獲得一些見解？謝謝。

Sure. So there are some moving parts. But I think 2024 is a good jumping off point, we will have some divestitures here either in late fourth quarter or early first quarter that would need adjusted. Certainly, the DPP programs, which are not in 2024 and not in our guidance that we're hopeful to get approved here in the fourth quarter, but we certainly expect those to be in place in 2025, assuming CMS approves those so that's kind of a meaningful change for us.

當然。所以有一些活動部件。但我認為 2024 年是一個很好的起點，我們將在第四季末或第一季初進行一些需要調整的資產剝離。當然，DPP 計劃不在 2024 年，也不在我們的指導中，我們希望在第四季度獲得批准，但我們當然希望這些計劃在 2025 年到位，假設 CMS 批准這些計劃，所以這有點對我們來說是一個有意義的改變。

In terms of disruption around the hurricane, it will take some time before we get insurance business interruption insurance settled. But some of this disruption that we're seeing here in the third and fourth quarter, we will be getting reimbursed through business interruption insurance. But again, that will take some time, and it's not going to be this year.

就颶風帶來的中斷而言，我們需要一段時間才能解決保險業務中斷保險問題。但我們在第三季和第四季看到的一些中斷，我們將透過業務中斷保險獲得補償。但同樣，這需要一些時間，而且不會是今年。

And I would hope that with the full year ahead of us in '25 that we can come to some agreement with the insurance companies and get that settled in in 2025 as well as having some reimbursement for property damage in 2025 as well.

我希望在 25 年即將到來之際，我們能夠與保險公司達成一些協議，並在 2025 年解決這個問題，並在 2025 年對財產損失進行一些賠償。

So again, some moving parts, but I think from base operations, we're continuing to make progress with some of our strategic investments, opening the new tower here in the fourth quarter that Tim mentioned earlier in the year, another one in Knoxville, and as we continue to recruit specialist and make other investments in outpatient locations, I think we can continue to grow volume and grow earnings from there.

再說一次，一些活動部件，但我認為從基地運營來看，我們正在繼續在一些戰略投資方面取得進展，蒂姆今年早些時候提到的第四季度在這裡開設了新塔，另一個在諾克斯維爾，隨著我們繼續招募專家並在門診地點進行其他投資，我認為我們可以繼續增加數量並增加收入。

I think that's well said. Stephen, I'll add on in terms of hurricane disruption. For the Pintogorda facility that remains closed, that's part of our short point health network, which has a larger hospital in Port Charlotte. We have been successful to migrating some of that care over to the Port Charlotte campus to mitigate some of that disruption of having a campus shut down, but we do not have the access for ED services.

我認為這句話說得很好。史蒂芬，我將補充一下颶風破壞的情況。對於仍然關閉的平托戈爾達設施，這是我們短點醫療網絡的一部分，該網絡在夏洛特港設有更大的醫院。我們已經成功地將部分護理轉移到夏洛特港校區，以減輕校區關閉造成的一些幹擾，但我們無法獲得急診服務。

We also had a larger behavioral health program that is running at a more reduced capacity at the Port Charlotte campus. So there's some things that we can't necessarily overcome within one quarter. So just want to put some color around that.

我們還有一個更大的行為健康項目，該項目在夏洛特港校區的容量有所減少。所以有些事情我們不一定能在一個季度內克服。所以只是想在它周圍添加一些顏色。

In terms of the timing of Milton unlike Helene happening in the last week of a quarter, with Milton being in the first week of the quarter, we do see opportunities to work those patients back into the surgical side, the procedural side of the business for sure through the remainder of the quarter. We stay close to those patients and providers.

就 Milton 的時間安排而言，與 Helene 發生在季度的最後一周不同，Milton 發生在季度的第一周，我們確實看到了讓這些患者重新回到手術方面的機會，即業務的程序方面。本季剩下的時間。我們與這些患者和提供者保持密切聯繫。

Right now, it's common the case after a major natural disaster. Those patients maybe don't come back the first week or second week after an incident like this. They're trying to get their homes and their lives back in order, but we believe we can get them back in by the end of the quarter.

目前，重大天災發生後的情況很常見。這些患者可能在發生此類事件後的第一週或第二週就不會回來。他們正在努力讓自己的家園和生活恢復正常，但我們相信我們可以在本季末讓他們重返家園。

Brian Tanquilut, Jefferies.

布萊恩·坦奎魯特，傑弗里斯。

Hey, thanks for letting me ask a follow up. Maybe, Kevin, as I think about the revenue per adjusted admission, the KPI for the quarter, just curious, I mean, as I look at the payer mix improving, Obviously, you called out acuity, but how should we be thinking about putting all that together in the outlook for revenue per admission.

嘿，謝謝你讓我詢問後續情況。也許，凱文，當我考慮調整後的入場收入、本季度的KPI 時，我只是好奇，我的意思是，當我看到付款人組合不斷改善時，顯然，您呼籲敏銳，但我們應該如何考慮所有這些都綜合在每次入場收入的前景中。

There's opportunity to continue to grow that. Certainly, getting acuity back will be beneficial. A couple of the other moving parts there, Brian, I would point out is with redetermination, and we've lost some Medicaid business, but we are picking up more in health care exchanges, which is beneficial to us. We have seen some movement from commercial insurance and the health care exchanges, which isn't beneficial, but still in the managed care numbers.

有機會繼續發展這一點。當然，恢復敏銳度是有好處的。布萊恩，我想指出的其他一些活動部分是重新確定的，我們失去了一些醫療補助業務，但我們在醫療保健交流方面獲得了更多，這對我們有利。我們看到商業保險和醫療保健交易所發生了一些變化，這不是有益的，但仍然存在於管理式醫療數據中。

We've had some geographic movement during this quarter. And not all commercial contracts and all locations are equal. So if you lose -- have lower commercial business in one location, that may have higher rates and you're picking up commercial business in another location that has lower rates. It's still flowing through is commercial business and commercial volume. But we may have been reimbursed less for it. So there was some geographic movement during the quarter.

本季我們進行了一些地域變動。並非所有商業合約和所有地點都是平等的。因此，如果你輸了——在一個地點的商業業務較低，那麼該地點的費率可能較高，而你會在另一個費率較低的地點獲得商業業務。流過的依然是商業業務和商業體量。但我們因此得到的報銷可能會更少。因此，本季出現了一些地理變化。

All that, I think, kind of washes out in the end over the course of the year. And we don't see that being a headwind for us going forward and I think will continue to grow off of that. Reimbursement rates, as you know, for Medicare are going to be favorable for next year. On our commercial contracting, we're seeing increases similar to what we've experienced this year. And then with some of the Medicaid DPP programs could materially increase our realization on Medicaid business going forward.

我認為，所有這些最終都會在這一年中消失。我們認為這不會成為我們前進的阻力，我認為這將繼續發展。如您所知，明年醫療保險的報銷率將會有利。在我們的商業合約方面，我們看到了與今年類似的成長。然後，透過一些醫療補助 DPP 計劃可以實質地增加我們對未來醫療補助業務的認識。

And then maybe, Kevin, one last for me. As I think about the divestitures, I mean, you sound fairly confident that we're still on track to hitting some of the goals there. How are you thinking about valuation and just the ability to close deals or I believe announced deals by year-end, given some of the moving pieces in the industry right now?

凱文，也許最後一個是我的。當我想到資產剝離時，我的意思是，你聽起來相當有信心，我們仍然有望實現其中的一些目標。考慮到目前行業中的一些動態，您如何看待估值以及完成交易的能力，或者我認為年底前宣布的交易？

Yeah. I would say for this $1 billion book that we're trying to get completed here, it's going to average out to about a 10 times multiple in these facilities will average out. There'll be probably high single-digit margin hospitals at 10 multiple. So one, it should help our leverage; two, it should help our margin profile going forward and that's pretty consistent with where our valuations have been in the past. Over the past several years, at least on average, where we've been in the 10 to 12 times multiple. So still feel very good about the multiple that we're getting and being able to get these across the finish line.

是的。我想說，對於我們試圖在這裡完成的這本耗資 10 億美元的書，在這些設施中，它的平均數將達到平均數的 10 倍左右。可能會有 10 倍的高個位數利潤醫院。第一，它應該有助於我們發揮槓桿作用；第二，它應該有助於我們未來的利潤率狀況，這與我們過去的估值非常一致。在過去的幾年裡，至少平均而言，我們的成長率是 10 到 12 倍。因此，我們仍然對我們獲得的倍數以及能夠衝過終點線感到非常滿意。

Awesome. Thank you.

驚人的。謝謝。

Josh Raskin, Nephron Research.

喬許·拉斯金，腎單位研究。

Hi, thanks for fitting me in here. So just want to confirm Tennessee and New Mexico. I know you talked about a potential retro of half year, maybe $50 million, $60 million. I assume that's not in guidance for 4Q, right? You're waiting for that to be completed at CMS level, right?

你好，謝謝你讓我來到這裡。所以只想確認田納西州和新墨西哥州。我知道你談到了半年的潛在回溯，也許是 5000 萬美元、6000 萬美元。我認為這不屬於第四季的指導，對吧？您正在等待 CMS 等級完成，對吧？

That is correct. It is not in our guidance for 2024. We've kept it out of guidance because it's not approved by CMS yet and had not previously quantified it. But at this point, we did want to quantify at least what annual math looks like to give you some insight on how we're thinking about this going forward.

這是正確的。這不在我們 2024 年的指導中。我們將其排除在指導之外，因為它尚未獲得 CMS 批准，並且之前也沒有對其進行量化。但在這一點上，我們確實想至少量化年度數學數據，以便讓您了解我們如何思考這個問題。

Got you. And then I'm just curious, we're hearing a lot about these IV shortages. And I'm curious if you're seeing any impact that you're at the hospitals in terms of procedures and at that level, are you seeing any impact from these IV shortages at this point?

明白你了。我只是很好奇，我們聽到了很多關於靜脈注射短缺的消息。我很好奇您是否看到醫院在程序和水平方面有任何影響，您是否看到目前靜脈注射短缺造成的任何影響？

Hey, Josh, this is Miguel Benet. So far, we have not experienced any operational disruptions in large part because [stocks] are not our primary source for IV fluids. We largely partner with BD for sourcing those stocks.

嘿，喬什，我是米格爾貝內特。到目前為止，我們尚未經歷任何營運中斷，很大程度上是因為[庫存]不是我們靜脈輸液的主要來源。我們主要與 BD 合作採購這些庫存。

Also, we are aware, of course, of the broader risk in the industry because of the shortages due to the Faster plant disruption and about potential buying across the industry to basically ramp up stock. So in preparation for that teams have implemented the logistics efforts and the shifting of inventory between our affiliate hospitals and basically stocking up so that we can stay ahead and keep our operations flowing without interruption.

當然，我們也意識到，由於工廠中斷速度加快而導致短缺，該行業面臨更廣泛的風險，整個行業可能會進行購買，以基本上增加庫存。因此，為了做好準備，團隊已經實施了物流工作，並在我們的附屬醫院之間轉移庫存，基本上進行了庫存儲備，以便我們能夠保持領先並保持我們的運營不間斷。

Okay. Perfect. And then just last one for me. Just on the exchanges. Do you get a sense of what percentage of your admits are coming from the exchanges at this point? And then has that slowed down at all as the reverification process in Medicaid has come to an end?

好的。完美的。然後是我的最後一個。就在交易所上。此時您是否知道您的錄取中有多少百分比來自交易所？隨著醫療補助的重新驗證過程結束，這種情況是否會放緩？

Our kind of percentage exchange business is about 7%, roughly, which is consistent with national averages of kind of the population enrolled exchange business. I think we're pretty close to national average as it relates to that. We've not seen any real material change recently, I guess, other than to say that we are picking up some additional exchange business as states have taken some of the Medicaid people off the Medicaid roles. We have seen a decline in Medicaid volume and a pickup in exchange volume without seeing much of a change in our uninsured business.

我們的交換業務的比例大約是7%左右，與全國交換業務登記人口的平均水準是一致的。我認為我們非常接近全國平均水平，因為它與此相關。我想，我們最近沒有看到任何真正的實質變化，除了說我們正在獲得一些額外的交換業務，因為各州已經取消了一些醫療補助人員的醫療補助角色。我們看到醫療補助數量下降，交易量增加，但我們的非保險業務沒有太大變化。

Thanks.

謝謝。

This concludes our question-and-answer session. I would like to turn the conference back over to Mr. Tim Hingtgen for any closing remarks.

我們的問答環節到此結束。我想將會議轉回蒂姆·興特根 (Tim Hingtgen) 先生發表閉幕詞。

Thank you, Dave, and thanks to all of you for joining our call today. As always, if you have additional questions, you can reach us at (615) 465-7000. Have a great day.

謝謝戴夫，也謝謝大家今天加入我們的電話會議。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。祝你有美好的一天。

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。