奎斯特診斷 (DGX) 2021 Q4 法說會逐字稿

Welcome to the Quest Diagnostics' Fourth Quarter and Full Year 2021 Conference Call. At the request of this company, the call is being recorded. The entire contents of the call, including the presentation and the question-and-answer session that will follow, are copyrighted property of Quest Diagnostics with all rights reserved. Any redistribution, retransmission or rebroadcast of this call in any form without written consent of Quest Diagnostics is strictly prohibited.

Now I'd like to introduce Shawn Bevec, Vice President of Investor Relations for Quest Diagnostics. Go ahead, please.

Thank you, and good morning. I'm joined by Steve Rusckowski, our Chairman, Chief Executive Officer and President; Mark Guinan, our Chief Financial Officer; and Jim Davis, our Executive Vice President, General Diagnostics and Chief Executive Officer-Elect.

During this call, we may make forward-looking statements and will discuss non-GAAP measures. We provide a reconciliation of non-GAAP measures to comparable GAAP measures in the tables to our earnings press release. Actual results may differ materially from those projected risks and uncertainties, including the impact of the COVID-19 pandemic that may affect Quest Diagnostics' future results include, but are not limited to, those described in our most recent annual report on Form 10-K and subsequently filed quarterly reports on Form 10-Q and current reports on Form 8-K.

The company continues to believe that the impact of the COVID-19 pandemic on future operating results, cash flows and/or its financial condition will be primarily driven by the pandemic severity and duration, health care insurer, government and clients payer reimbursement rates for COVID-19 molecular tests, the pandemic impact on the U.S. health care system and the U.S. economy, and the timing, scope and effectiveness of federal, state and local governmental responses to the pandemic, including the impact of vaccination efforts, which are drivers beyond the company's knowledge and control.

For this call, references to reported EPS refer to reported diluted EPS and references to adjusted EPS refer to adjusted diluted EPS. Any references to base business, testing, revenues or volumes refer to the performance of our business, excluding COVID-19 testing. Growth rates associated with our long-term outlook projections, including total revenue growth, revenue growth from acquisitions, organic revenue growth and adjusted earnings growth are compound annual growth rates. Finally, revenue growth rates from acquisitions will be measured against our base business.

Now here is Steve Rusckowski.

Thanks, Shawn, and thanks, everyone, for joining us today. Over the past 2 years, our 50,000 Quest employees have risen to the challenge of COVID-19 innovating, persevering and remaining committed to the patients and customers we serve. While doing so, they also grew our base business by more than 19% in 2021, achieving record levels. I'm extremely proud of what we have accomplished as a team. So we have a lot of news to cover this morning, and I want to get into that so we can have your questions.

So let's get started. So first, I'll start by sharing some color on the leadership transition we have announced this morning. Then we'll review our performance for the fourth quarter and the full year of 2021. And then finally, Mark will provide more detail on our financial results and talk about our financial outlook for 2022. So as you have seen, in our announcement this morning, we've begun implementing a gradual leadership succession plan under which Jim Davis, Executive Vice President of General Diagnostics, will succeed me to become Chief Executive Officer on November 1, 2022. At that time, I will continue to serve on the Quest Board of Directors as Executive Chairman.

Quest Diagnostics is a great company that is well positioned to continue to deliver shareholder value. As I approached a decade in the role, the Board and I determined that now is the right time to begin to turn over to a new leader. Jim Davis is extremely well-qualified to be CEO, having managed a large part of this company in his role as Executive Vice President. He has deep knowledge of Quest in the health care industry and the corporate world gained through more than 35 years of business experience. Jim is widely respected and will be a strong CEO.

When I took this role nearly 10 years ago, Quest was not growing nor realizing its potential. We launched a new strategy, Our New Quest, to drive transformational change. To drive that change, we built a new leadership team, and Jim has been a key member of that team. We built a business strategy to accelerate growth and drive operational excellence.

To drive growth, we focused on improving relationships with health plans and hospital health systems. In expanding fast-growing businesses in advanced diagnostics and consumer testing. In addition, we've added about 2% revenue growth on average through accretive strategically lying acquisitions over the last several years. We have driven operational excellence, and our invigorate program has consistently improved quality, and customer experience while generating 3% productivity each year. And we've made more inclusive by increasing the diversity of our Board and amongst our management ranks.

Finally, we established Quest for Health Equity in 2020, over $100 million committed to reduce health care disparities among underserved in the United States, particularly in communities of color. I am very proud of what we have accomplished together. And if you consider the opportunities in front of us, in many ways, we're just getting started. We have a strong team, and Jim has been a key leader in our transformation. He runs our General Diagnostics business, which accounts for more than 80% of revenues and 3/4 of our employees. He manages operations, including sales and marketing, patient services, logistics, laboratories, billing and customer services. He also oversees the drive operational excellence strategy, which includes our Invigorate program. He has provided enterprise oversight for a pandemic response. And if that wasn't enough, he's also led the development of Quest ESG strategy.

So Jim, congratulations. I look forward to working very closely with you through this transition.

Thanks, Steve, and I really look forward to working closely with you over the next 8 months and ensuring a very successful transition. It's a tremendous honor to have the opportunity to see you in Quest and lead Quest into the next phase of our growth. We have a very powerful vision at Quest of empowering better health and diagnostic insights. Our business strategy is straightforward and well understood. And our company have never been more central to patients and to the health care system as we've seen during this pandemic. I really look forward to working with the management team and all 50,000 employees to build on the strong foundation that Quest has put in place. Quest's future is really bright, and we're extremely well positioned to continue to create value for our shareholders and all that we serve.

Thanks, Jim. Now at the same time, Mark is planning to retire this year. Mark has been in his role for more than 8 years and help navigate us to the strong position where it is today. We have begun a process in which I will be working closely with Jim to identify Quest's new CFO, and Mark will participate in the selection process, he will remain in the roll through the transition. Mark, I want to thank you for your many contributions, your partnership and your friendship. You've been a key member of our leadership team, and we have transformed Quest and accelerate its growth.

Thanks, Steve. I appreciate the kind words. I just want to take a minute to say that I'm proud to be part of an important company that makes a positive contribution to the country. And I've enjoyed being part of it. Now it's time for me to step back and retire. I'm looking forward to participating in the process to identify my successor who can support Steve and Jim in Quest's next phase of growth.

Now turning to our results. We closed out 2021 with another record year of revenue, earnings and cash from operations. Our base business recovered throughout the year, and we experienced strong demand for COVID-19 testing services. So for the full year 2021, total revenues grew by more than 14% to $10.8 billion. Earnings per share increased by nearly 49% on reported basis to $15.55 and more than 27% on an adjusted basis to $14.24. Cash provided by operations increased by more than 11% to $2.2 billion. And for the fourth quarter, total revenues were $2.7 billion, a decrease of roughly 9% versus 2020 when COVID-19 volumes were surging.

Earnings per share were $3.12 on a reported basis and $3.33 on an adjusted basis, both down approximately 26% versus the prior year.

So I'd like to share some perspective on the role of COVID-19 testing going forward. A lot of progress has been made in the battle against COVID-19, but we believe it isn't going away anytime soon. Our molecular volumes began this year strong with volumes peaking in mid-January. Testing will continue to play an important part of managing COVID-19, and we believe that molecular testing remains the gold standard. We continued to perform well throughout this surge, maintaining average turnaround times of 2 days or less for COVID molecular testing. We will continue to maintain appropriate testing capacities and staffing levels to be prepared for any additional surges throughout this year if they emerge.

We also continue to believe there will be a bigger role for serology testing and how we measure COVID-19 protection going forward. Ultimately, we expect COVID-19 testing to eventually more flu-like and become a permanent part of our portfolio going forward.

Now turning to our base business. We continue to make progress executing our two-point strategy to accelerate growth and drive operational excellence, while we delivered 2% revenue growth on our base business from acquisitions again last year. In the fourth quarter, we acquired the assets of Labtech Diagnostics, a regional independent laboratory serving physicians and patients, primarily in South and North Carolina, Georgia and Florida. This is the first full-service laboratory owned by Quest in South Carolina. We also recently announced our acquisition of Pack Health, a patient engagement company that helps individuals adopt healthier behaviors to improve outcomes. This acquisition will bolster our extended care capabilities.

Since 2012, we have completed more than 40 acquisitions, including outreach laboratories, regional independent laboratories and capability-enhancing deals. And over the last 4 years, we have achieved our target of greater than the average of 2% revenue growth in our base business each year from acquisitions. And then finally, our M&A funnel remains strong.

In 2021, we took full advantage of our strong health plan access which is approximately 90% of all commercially-insured lives in this country. We also made good progress working together with health plans to help companies and their employees save money by reducing denials and out of network leakage. Health plans also recognize the value of working with us, and we have grown our health plan revenues faster than our overall revenues to the best level we've ever seen.

Hospital health system revenues have grown more than 20% compared to 2019 levels, excluding COVID-19 testing, driven largely by the strength of our professional laboratory services contract. Our performance in 2021 benefited from our 2 largest PLS contracts to date, Hackensack Meridian Health and Memorial Hermann. Altogether, our PLS business, without COVID-19, exceeded a record $500 million in annual revenue last year. The hospitals have continuously faced pressure throughout the pandemic.

Post-pandemic, we believe the same will be true. We believe there will be a continued consolidation and ongoing challenges to afford Quest an opportunity to implement our flexible solutions to help hospitals become more effective and productive. Advanced diagnostics is critical to the future of health here. We're building strong momentum in our key growth drivers, which include consumer and hereditary genetics, oncology and pharma services.

In 2021, these test categories accounted for several hundred million dollars of advanced diagnostics portfolio, and they're growing more than 25% versus 2020 and nearly 33% versus 2019. We are investing aggressively in areas with potential for future differentiation to grow our advanced diagnostics value proposition, including automated test, next-gen sequencing, bioinformatics, the sales force and customer service. We're leveraging our scale and expertise to give patients and providers greater access to important innovations such as liquid biopsy and digital pathology.

Advanced diagnostics is one of the faster-growing areas of our portfolio. Our strategy and investments in this area will enable us to achieve high single-digit revenue growth going forward. And we're equally excited about the opportunities we see in our direct-to-consumer testing business. Revenues for QuestDirect services nearly doubled to more than $70 million in 2021, driven by both the base business growing and COVID-19 testing.

We expect the non-COVID consumer diagnostic market will experience double-digit growth over the next several years, and we're on track to build the $250 million direct-to-consumer business by 2025. We're ramping up our investments into the business, launching a new and improved digital experience later this year. And we're also investing in enhancements to the in-person customer experience at our patient service centers. So we're off to a good start in 2022. We're building on a long-term relationship with Walmart by recently launching a consumer-initiated laboratory testing on walmart.com through our solution powered by QuestDirect. And the MyQuest platform now has nearly 23 million users, up more than 3 million in the past quarter.

We're very excited about our longer-term growth opportunities in advanced diagnostics and direct-to-consumer testing and are increasing investments we made in 2021 to strength in our business and accelerate growth beyond the pandemic. These investments were made possible with the record cash and earnings we generated over the past 2 years.

Now the second part of our two-point strategy is to drive operational excellence. We remain laser-focused on improving both operational quality and efficiency, which go hand in hand. During 2021, the Invigorate program exceeded our goal of 3% productivity improvement. We made good progress last year in procurement supply savings as well as reducing health plan denials and improving patient collections at the time of service.

While we faced modest inflationary wage pressure in 2021, on the supply cost side, we have more than offset any increases with cost savings from our suppliers. Historically, our Invigorate productivity savings have been net of any inflationary increases. Beyond that, we continue to drive additional productivity improvements with platform consolidation and greater use of automation and artificial intelligence.

Now turning to our sales force -- excuse me, now turning to our workforce. Quest employees are highly engaged based on results of our quality surveys. In a challenging labor market, we are focused and are still seeing improvement in engagement and retention. Our team has done a lot to create an inspiring workplace, and we continue to do everything we can to attract, recruit and retain talent.

We're entering 2022 in a strong position within the lab industry and more broadly throughout health care. Our base business is poised to build off the record revenues we've achieved last year, and we're investing to accelerate growth. We expect to see continued demand for COVID-19 testing services, albeit at lower levels in the last 2 years. The delay of the 2022 PAMA cuts announced last year was a good outcome for our industry and medicated beneficiaries. However, it will continue to be hard at work in 2022 with our trade association and members of Congress with the goal of arriving at a permanent fix to PAMA. We remain committed to our capital deployment strategy of returning the majority of our free cash flow to our shareholders.

This morning, we raised our dividend for the 11th time since 2011. We expect to have more than $1 billion in cash available this year for M&A and share repurchases. So putting it all together, our 2022 guidance reflects strong momentum and investment in our base business, balanced with inevitable but expected decline in COVID-19 testing revenues.

Before turning it over to Mark, I'd like to recognize and thank once again all of our employees who really have been the front line of the pandemic and continue to serve the health care needs of patients who depends on Quest every day.

Now Mark will provide more detail on our performance and our 2022 guidance. Mark?

Thanks, Steve. In the fourth quarter, consolidated revenues were $2.74 billion, down 8.6% versus the prior year. Revenues for Diagnostic Information Services declined 8.5% compared to the prior year. The decline reflected lower revenue from COVID-19 testing services versus the fourth quarter of 2020, partially offset by continued growth in our base testing revenue. Compared to 2019, our base DIS revenue grew approximately 6% in the fourth quarter and was up more than 1%, excluding acquisitions. Volume, measured by the number of requisitions, increased 1.3% versus the prior year, with acquisitions contributing 1.1%.

Compared to our fourth quarter 2019 baseline, total base testing volumes increased more than 10%. Excluding acquisitions, total base testing volumes grew approximately 5% versus 2019 and benefited from new PLS contracts that have ramped over the last year. The progress we made in our base business throughout 2021 continued in the fourth quarter, and base testing volumes remain consistent with our prior outlook.

As many of you know, COVID-19 testing volumes moderated early in the fourth quarter, following the peak of the Delta wave in September, but then surged again in early December as the Omicron variant spread across the U.S. Together, with our JV partner, Sonora Quest, we resulted approximately 7.9 million molecular tests. Quest alone resulted roughly 7.3 million molecular tests and nearly 730,000 serology tests in the fourth quarter.

In January, our COVID-19 molecular volumes averaged approximately 120,000 tests per day and over 139,000 per day, including Sonora Quest with volumes peaking in the middle of the month. Revenue per acquisition declined 9.8% versus the prior year, driven primarily by lower COVID-19 molecular volume. In the fourth quarter, increases in our base revenue per requisition were more than offset by the impact of recent POS wins. Modest unit price headwinds remained consistent with our expectations. Reported operating income in the fourth quarter was $536 million or 19.5% of revenues compared to $795 million or 26.5% of revenues last year.

On an adjusted basis, operating income in Q4 was $579 million or 21.1% of revenues compared to $860 million or 28.6% of revenues last year. As you may recall, the updated 2021 guidance we shared in October contemplated a lower adjusted operating margin both year-over-year and versus 3Q. The year-over-year decline was primarily driven by lower COVID-19 testing revenues and higher COVID-19 testing costs, headcount and wage increases and ramping strategic growth investments.

It's important to note that over time, a growing portion of our COVID-19 molecular testing volumes have come from nontraditional channels, which carry additional expenses and logistics costs. Also, spiking COVID-19 positivity rates across the country in December eliminated our pooling capability, which further increased COVID-19 testing costs late in the quarter. In addition, we also experienced higher than anticipated employee health care costs in the fourth quarter, primarily related to COVID-19.

Reported EPS was $3.12 in the quarter, compared to $4.21 a year ago. Adjusted EPS was $3.33 compared to $4.48 last year. Cash provided by operations was $2.23 billion in 2021 versus $2.01 billion in the prior year. We completed our $1.5 billion ASR in November and repurchased an additional $310 million in stock in the fourth quarter. This brings total share repurchases to more than $2.2 billion in 2021 and we ended the year with $872 million on the balance sheet.

Before turning to guidance, I'd like to comment on recent trends we've seen in our labor costs. As Steve noted, we've been managing through a challenging labor environment. While wage inflation, including our annual merit increase is expected to be between 3% to 4% this year. The increase in our total salaries, wages and benefits is expected to be below 3% in 2022, given the reset of our annual performance compensation and lower expected overtime. As a reminder, all of our employees are eligible for annual performance.

Now turning to guidance. We estimate full year 2022 results as follows: Revenue is expected to be between $9 billion and $9.5 billion, a decline of approximately 12% to 17% versus the prior year. Base business revenues are expected to be between $8.3 billion and $8.5 billion, an increase of approximately 3.5% to 6%; COVID-19 testing revenues are expected to be between $700 million and $1 billion, a decline of approximately 64% to 75%. Reported EPS expected to be in a range of $7.63 and $8.33 and adjusted EPS to be in the range of $8.65 to $9.35. Cash provided by operations is expected to be at least $1.6 billion, and capital expenditures are expected to be approximately $400 million.

Before concluding, I'll touch on some assumptions embedded in our 2022 guidance. As Steve said, we're entering 2022 in a strong position. Our guidance assumes COVID-19 molecular volumes to average between 65,000 to 80,000 tests per day in Q1, representing a decline from January levels and approximately 20,000 to 35,000 tests per day for the full year. For COVID-19 serology volumes, the guidance assumes approximately 3,000 tests per day for the full year. While our guidance does not currently anticipate another COVID wave, we'll remain ready from an operational standpoint to handle any future surges.

Last month, the public health emergency was again extended another 90 days through April. We assume average reimbursement for COVID-19 molecular testing to hold relatively steady through this period. While the public health emergency could continue to get renewed beyond April, additional extensions are not captured in our guidance. The earnings we've generated from COVID-19 testing have afforded us an opportunity to continue to increase investment in our business.

As Steve noted earlier, we continue to ramp investment in our growth pillars, particularly the advanced diagnostics and direct-to-consumer testing opportunities. We are planning to invest approximately $160 million in our growth initiatives this year which represents an additional $90 million in investments in 2022 versus 2021. We also continue to incur higher costs to manage our business through the pandemic, including expenses to comply with CDC guidelines, address ongoing supply chain challenges and maintain adequate staffing levels.

We currently forecast these expenses to be approximately $50 million in 2022. As a reminder, we originally expected PAMA cuts of approximately $80 million in 2022. These cuts were delayed 1 year until 2023. Finally, we ended 2021 with approximately 124 million diluted shares outstanding. Our guidance assumes no change in our share count in 2022 and only enough share repurchases to offset our employee equity programs and to meet our commitment on the majority of our free cash flow to our shareholders.

I will now turn it back to Steve.

Thanks, Mark. Well, to summarize, we had another record year, providing critical COVID-19 testing to our country and delivered record revenues, earnings and cash from operations. We also grew our base business to a record level, up 19% versus the prior year. Quest is well positioned in 2022 to deliver on its commitments. I'm proud of the incredible accomplishments of our 50,000 Quest employees throughout the pandemic. And finally, our team is strong, the business has good momentum, and Quest's future is bright as we begin a gradual transition to new leadership.

Thank you. We'd be happy to take your questions.

(Operator Instructions) The first question is coming from Jack Meehan, Nephron Research.

First, I know this isn't the end, but congrats, Steve and Mark, on the retirement. And Jim, congrats on earning the big seat. Agreed this is very well deserved for you.

Thank you, Jack.

Thanks, Jack.

Thanks, Jack.

So first question, there's been a lot of anxiety around pressures in the lab industry, which I personally find very interesting because historically, that's actually been the bull case for Quest. So it would just be great to get your thoughts on what you're hearing from hospitals around outsourcing? Have you picked up any new contracts and potential for share gain versus some of these regional independent labs?

Yes. Thanks, Jack, for the question. And there is a lot more pressure in our industry and particularly at early hospitals. And so we are seeing continued interest in our working with hospital systems and helping them become more efficient and productive with our professional lab services business, so that continues to be a big opportunity. You saw in our prepared remarks that grew nicely over the last couple of years. We have a $0.5 billion business. And therefore, as that moves, it moves our enterprise a significant level. So that's number one.

Number two is we are very strong, and we continue to drive operational excellence. As you all know, this is not new. It's institutionalized in Quest. We believe we have the cadence and the capabilities to continue to offset any inflationary pressure we have, and we've done that. We did it last year, and we'll continue to do that going forward. And as I said in my introductory remarks, we already included in Invigorate when we talk about inflationary pressures on our cost of sales. We provide Invigorate savings, it's a net number. So any increase is offset by the savings and it's always been positive for us. We're getting more savings than cost increases. And so despite some pressures that we see because of the current times, we're offsetting that.

And going forward, we do see that smaller laboratories will have a tougher time, keeping up with some of these pressures. And therefore, we do have an advantage. And we saw the acquisition we just did of Labtech in South Carolina. We are achieving that 2% growth from acquisitions. So therefore, we believe our strategy has positioned us nicely going forward to take advantage of the changes in front of us given this different time than we've ever seen.

So Mark, anything you like to add to that?

Yes. I think the other thing that's evolving, Jack, that you didn't mention, but I'm sure is on your radar is moves towards transparency on pricing, whether it's surprise billing. Now it certainly is complicated. So even for us, it's not simple. It depends if you got commercial insurance, it depends on who your carriers and so on. So it's not simple to tell people exactly what their cost is. However, it's absolutely an advantage for the national assets, specifically for Quest. So we're encouraged by some of this -- kind of, one of those secrets that a lot of people aren't aware, how much better our value is compared to others. And so we really see that together with some of the other things you mentioned as another reason that we're going to continue to pick up share and really return to those growth rates we were having before the pandemic started with greater access and then all the tools and value that we bring well beyond our price, including our real-time estimation tools, including our MyQuest app and all the other things that really enhance the patient experience.

Great. And as a follow-up, on the disclosures around the fourth quarter detection testing, $7.9 million total, $7.3 million resulted by Quest or $600,000 through the referral network. Can you talk about just the profitability on the tests that go through the referral network versus those resulted by Quest because I think people are just trying to figure out the relative margin upside versus revenue? I'm wondering if maybe that was a factor we weren't considering.

Yes. So to be clear, it's not through referral network. We have a JV with the Sonora Quest. And so we wanted to make sure that people were aware if they were doing some math around rev per req on the testing volumes that we don't actually report that revenue because we have a minority ownership stake. So we get a proportional share of the earnings from Sonora Quest as we do with our minority holdings, as we do with our majority holdings to equity earnings. So we just wanted to provide that transparency. But in terms of the pricing and so on and so forth, I won't comment specifically on Sonora Quest. But it's not dissimilar. It's not a totally different profit structure than the things that we do ourselves.

And Jack, during the surge, less than 5% of our total volume is set out to a referral lab. And at this point in time, it's back down to 0. So it's only during the surges that we have to rely on these external partner labs to help us.

Yes. What I did refer to, Jack, and maybe that's what you were asking about was nontraditional channels. And so that's not where we're sending the work. It's actually how we're getting the specimens. So a lot of the work, especially early was through our traditional channels. Our hospital partners where we were going anyways, we collect specimens and we would leverage all of the Quest logistics, all in cases where we had people going to our patient draw centers, we're leveraging that. In this case, we're actually getting it from other providers. CVS is the most notable one.

And as we do that, we have to have incremental logistics structure. We have to have incremental logistic runs and then we do pay a fee, you kind of should think about it kind of like phlebotomy. But all the work they do to collect the specimen and to engage in administrative cost of the patient to give them the results. And so there is, I think, a cost that maybe people weren't aware of when we're not getting that specimen through our traditional infrastructure.

The next question is coming from Ann Hynes, Mizuho Securities.

Congratulations to Steve, Mark and Jim. So I just want to ask about margins because, obviously, the stock's down or underperforming year-to-date versus some peers. And I think there's a debate on the Street about the margin profile for Quest ex-COVID. I know your guidance assumed margin pressure in Q4. It was worse than expected. And a follow-up to that is -- again, you just started 2022, people have really focused on what your margin profile will be in 2023. And in your prepared remarks, Mark, you did talk about some growth initiatives that are in 2022, the $160 million. And I think you said $50 million for incremental cost. But I guess like there are so many moving parts with extra labor costs, extra supply cost, you have these growth investments. I guess if we look out to 2023, not giving guidance, like what do you think is repeatable and what is not? And maybe if you can just comment on just the health of how you view your base margins in the base business, that would be great.

Yes. So thanks for the question, Ann. I think it's an important one. So first off, we're not deviating from our long-term outlook. So we shared a long-term outlook in March of 2021. And while the CAGRs are going to change because we're going to have a stronger year in 2022 and the CAGRs, I quoted at that time we're putting 2022 forward. The absolute numbers we're not deviating from because they're largely the base business. So we still assume that COVID will materially decline. Time will tell. And at that point, it's really all around our base business.

So when people are looking at the current profitability base business, and I can understand how this happens, one of the flaws in that is that they really -- you can't really do the 2 in isolation. So let me give some examples. Because we've had such a surprising strong year this year relative to what we expected, driven by COVID, we're paying a significantly higher incentive performance bonus, and that's across the whole employee base. And right now that would not be expected to be repeated next year. So that "inflated our cost." And so to assign all of that cost against the base business, which is what implicitly is done, when you assume COVID revenues times a certain margin drop-through and then you assume backing into the base business, that is just not accurate.

The other thing is we have significant incremental costs related to the pandemic which I mentioned in the prepared remarks, around $50 million of cost. If COVID really goes away, we would expect those costs will largely go away. And those costs would really be assigned to COVID, not to the base business. We had quite a bit of overtime later in the year, and that was related to employee absences driven by the COVID surge. And we spent about $25 million more in 2021 than we historically spent in over time. And we would expect that would go away as well as COVID starts to step back.

And so again, that is implicitly put against the base business when you do the high-level math that I've seen a lot of people do. And so the way to think about the base business is obviously from our guidance, we are hundreds of millions of dollars above where we were in 2019. We expect to be back to the growth that we were experiencing pre pandemic. I know it seems like a long time, but if you look at the first 2 months and we mentioned this several times of 2020 before the pandemic started, even after a full year of the network access gains we had in 2019, we were still growing mid-single digits. We're going to get back to that growth, okay, in the base business. And the profitability of the base business is going to be similar to what it was before 2019. So hopefully, that puts all the pieces together for you. Obviously, if there's anything I didn't clarify, I'd be happy to take a follow-up.

No, that's very helpful. And just as a follow-up, just to your growth initiatives, like the $90 million incremental in 2022, how should we view that for 2023?

Right. So some of those will ramp down because there are discrete investments to get us where we need to get to. So for instance, a big piece of that is building what we need for our consumer-initiated testing. And to move from where we were to more Amazon-like and that, that will get completely there, but experience for patients who want to find, test and order it, pay their bill, et cetera, is expensive. It takes a lot of work. The marketing analytics to do the appropriate marketing and understanding of customer preferences and respond to customers in an appropriate way. There's a lot of IT investment in the near term to get us to that future state.

Now as we're growing that business to $0.25 billion, which is what we said we would get to by 2025, there are going to be some ongoing costs because we're adding people to support that business. It is an incremental business, and there are going to be some variable costs with that. However, as we grow those businesses, we're going to grow faster. And so some of those ongoing costs are going to get paid for that faster growth. And then I would say, similarly, in advanced diagnostics, as we accelerate that growth, some of the resources we're adding today that we're calling out pre that growth are going to be in the run rate and profitability going forward. So the costs don't go away completely, but they will ramp down because some of this is kind of start-up expenses. And then that revenue obviously and the margin is going to pay for those incremental costs over the next several years.

Yes. Let me just add to that. Remember, when we talk about this year, these investments really started in the back half of 2020. We talked about an exceptional year in 2020. We talked about an exceptional year in 2021. And therefore, we took advantage of the opportunity invested in accelerated growth, entirely consistent with what we shared with you is our growth portfolio. And what you're seeing in our results already is the benefits of those investments. You're seeing great growth in our focused areas of advanced diagnostics. I highlighted those areas of our portfolio that we're focused on. And these are not insignificant portions of our portfolio.

I shared in my introductory remarks, these are several hundred millions of dollars of focus for us that are growing strong double digits versus last year versus 2019. And then secondly, is our consumer-initiated testing business has grown considerably, and we talked about $70 million [on half of] $250 million. And so therefore, we're always starting to see the benefit. So as with any investment, we expect a business return, we're getting some of that business return already, '21, we'll expect more of it in '22. And so when you get into '23, you've got to trust that we'll not start at the beginning.

What we're putting our rides on is exactly what we laid out at Investor Day that as we have a baseline coming out of '22 that we believe in and what we just shared in our '22 guidance is entirely consistent with that and that we will continue to grow our earnings, that had steer growth, we highlighted 7% to 9%, and that will continue into '23 and then in '24. So we feel what we've done so far and what we've delivered is entirely consistent with what we believe the prospects of we do believe the opportunities for us are even more attractive than before because we've had proceeds for the benefits of COVID's accelerated growth that we believe is real.

Yes. Just one clarification. So the 7% to 9% was when we thought we reduced $7.40 to $8 in 2022. And we said we'd be at the upper end of that. So you can pick your number between $7.40 and $8, $7.40 -- $7 to $8 through '23 and '24. And that dollar level of EPS is what we're saying we can still do. Obviously, since 2022 is turning out based on our guidance, a lot higher than we said in March, the CAGR is going to be lower, but the absolute numbers, we're still committed to at this point.

The next question is coming from A.J. Rice of Credit Suisse.

Best wishes on the transition to all. Maybe just to ask M&A pipeline: a, any update on what you're seeing out there with the opportunity set looks like? B, does the management transition caused you in any way to pull back or to pivot in a different direction in inorganic growth prospects? And then just maybe finally on the Pack Health deal. That was obviously not a huge deal, but an interesting one. Does that suggest they pivot? And what's sort of the opportunity there with that acquisition?

A.J., thanks. We continue to believe that we can continue to deliver that 2% growth of our base business going forward. We've delivered that in the past, and we have every reason to believe that will continue going forward. As I mentioned earlier, we're going to continue to see hospitals looking at what we've done with other hospitals an opportunity for them to rely on us with the testing and that product continues to build, and we continue to look at some outreach purchases with hospitals.

And then as I mentioned, Labtech was a good example of a regional laboratory and a good piece of the United States that we picked up as well. And we continue to look at acquisitions that build on our portfolio. Remember, we have this lens of focusing on general diagnostics, and Jim Davis runs that business, in addition to that, advanced diagnostics.

But the third piece is -- are those services that take the information that we generate we provide services. And we do this employer population health, and we've built on that business to work with health plans and helping them manage their risk with the data and providing services that help them with that. So Pack Health fits into that direction for the company, and we've done some other acquisitions that help us with that direction as well. And you're going to hear more about our continued investments within that space going forward. And also in your question, the management changed slow us down in any way, impair what we might do with acquisition. I would say to the contrary, Jim has been part of the management team for over 8 years. He's highly engaged in all acquisitions. He's been instrumental in executing a lot of our acquisitions and all the businesses that we participate in are always part of the funnel building that we have.

So Jim, any remarks about the 40 acquisitions we've done and you're team to find more opportunities.

No, A.J., as Steve said, I've been part of all 40 of those acquisitions, and it's not going to slow down. We're not going to do -- we're going to do smart deals. We're going to be selective. So if we're going to continue to build our base business, we're going to continue to find niche applications to build out our advanced diagnostics portfolio. And we're going to continue to focus on hospital outreach deals, those that are willing to get out of the business, we're right there, ready to help them.

The next question is coming from Patrick Donnelly of Citi.

Maybe just one on some recent payer negotiations. Obviously, you guys have talked a lot about inflationary pressures and supply chain things. How much does that come up in kind of the negotiations with payers? Are you able to pass that along? I know you guys are in a pretty good place with payers relative to historic levels. So maybe just talk through some of those conversations and ability to pass price along and price increases in those payer contracts?

Yes. Thanks, Patrick. Well, so there's a lot of attention these days on inflationary pressures, and we think we've handled those questions. We think it's all very manageable for us in terms of our operational excellence programs and finding the productivity we need to offset it. So that's one piece of the equation. The other piece is what you're bringing up is around pricing. And we feel good about what we have delivered in that regard. And as I said, if you look at the results for '21, what you find is that there are unit price changes, and this is freezing everything from volume and mix, and just looking at even price changes, is below that 100 basis points that we typically have guided you to, dial in to expectations going forward. And that's not just for our commercial insurance contract. It's all our business. It's our hospital business. It's our client business, independent of who those clients might be physicians or some other organization we work with.

So we continue to make progress on that, and we're particularly encouraged by the discussions we're helping with health plans. We have shared in the past that actually in the past, several negotiations, we've actually introduced price increases, and it is actually helping us that, in fact, there is inflationary pressure across all of health care. So therefore, we're not alone since we're a labor-based business to pass along some of those costs to them. So we're making good progress. And I'd say the other piece of this, Patrick, is we continue to deliver great value. Our quality gets better, our service gets better, and we do that at a very competitive price already. And many of these plans believe that's in the best interest of them and their membership of growing share is to make sure they rely on a handful of topflight laboratories in the case of UnitedHealthcare, they call that for lab network. And we have applied to that, and we had to demonstrate with other names. Matter of fact, we have great quality, we have great service, and we're doing that at very competitive prices. So that trend will continue.

When you talk about value, we're going to eventually keep on pushing that to deliver more and more value, which helps you in terms of managing your network. We, in many cases, are going to start looking at some price increases going forward. So good progress there. Thanks for asking the question. Mark, anything you'd like to add?

Yes. I just want to remind people of what we've talked about over our tenure. We have this Invigorate program drives about 3% productivity. And we call it productivity because some of it is top line enhancing. It's not all-around costs. And we've mentioned the fact that we have these pay force. And one of them has been price erosion. One of them has been annual labor inflation. And then we talked about the fact that as we've got price in a better place that actually was helping with margin expansion. So we had enough productivity to do more than the pay for us.

So now you look at where we are today, and as Steve mentioned, a much better position. I can't specifically say it's related to inflation. But I can assure you that, that is part of the conversation in addition to PAMA and the value that we bring and so on. So we've really moved the conversation dramatically from when we started here to more about value. And fortunately, for us, I can share that in the last 3 national payer contracts, all 3 of them, we've got an increase. That was modest. But you compare that to where we've been historically, great news. And that also means that even if we have a little more inflation, and I think we've talked about this quite a bit, we've got plenty of Invigorate. And that Invigorate now doesn't need to cover as much of the price erosion that we had historically.

And that price erosion that Steve shared is really heavily in the client bill. And as we've talked over the last number of earnings calls, that comes from both our hospital clients who are under tremendous pressure, and share the reasons for that. And also in some states where physicians can do client bill markup, we have that pressure as well. But really with the commercial payers, we're in a really good place on price lately.

That's really helpful. I appreciate it. And then just a quick follow-up on COVID, maybe pricing and volume. You mentioned no expectation for the PHE to continue to be extend it in the second half or at least it's not baked in, sorry. How do you think about the pricing piece, both commercial? Will they follow kind of -- and wait for the PHE? And then on the volume side, are you expecting it to be endemic. A lot of the diagnostic players have obviously talked about multiple years of COVID revenues going out? Just curious on your take there.

Yes. So what we're assuming in our guidance is we've given some ranges of what we think COVID testing will be. And obviously, it's going to start higher in the first quarter, and it's going to go down, as we are hopeful that this current surge will decline throughout the spring and into the summer. And as you mentioned, we did get the 90-day extension. And we're not planning in the guidance that, that will be extended, but we just don't know. So therefore, we're always assuming the worst case. And that if that were to come down, yes, we do believe there will be some recent price changes, if you will, with some of our partners. But again, what we've implied in the guidance is a decline in volumes and some decline in pricing. And also the assumption that we're not going to get a renewal of the emergency order. But again, we don't know that. So Mark, anything you like to add?

Yes, just a reminder, it's not that I need to remind you all, but the rate that CMS determines $51. And so while we don't assume post-PHE that everything calls immediately there, there's a pretty steep ramp down. And then so for the volume that is in our guidance beyond the PHE in late April, we're assuming a significantly lower reimbursement than we've experienced to date and that we're expecting through late April.

The next question is coming from Ricky Goldwasser, Morgan Stanley.

Best wishes to all of you. Jim, you're going to be my fourth Quest CEO, I'll be working with, so very excited. Dating all the way back to Ken Freeman's days.

So just wanted to go back to sort of what the 2022 baseline is? It seems that this is kind of like really the bulk of the questions that we're getting from investors sort of how should we think about the 2022 a normalized baseline that we can build off for 2023? I know that you kind of said in response to one of the questions that in terms of absolute EPS, you are where you expect it to be last year. But maybe you can give us a range, we're getting to somewhere between kind of like $7.60 to $7.80 is a normalized base on for -- to -- is it starting point? Just wanted to kind of see if we're in the ballpark. And then of that, maybe just qualitatively, what are the headwinds and tailwinds that we should think about as we think about modeling out to 2023?

Go ahead, Mark?

Yes. So I'm sure you understand, Ricky, even if I was willing, I can't really give you an EPS number on the base business. So I think the best thing I could do is point you to pre-pandemic revenue and earnings and tell you that if you look at the growth in the base business based on at that time we're giving in guidance, the profitability is not dissimilar. So that you can kind of directionally place that business might be. And the reason I can't really give, is back to what I talked about earlier.

So where do I sign the $50 million of pandemic expense. Arguably, if we didn't have COVID testing, we would still have that cost and you'd say, okay, well, that should go about your base business. But the truth is that we also have the COVID testing and revenue. So we should go against the COVID revenue, should go against the base business. And then importantly, when you talk about headwinds and tailwinds, we would expect that cost to go away. It shouldn't be temporary because it is specifically tied to CDC guidelines and other things.

We talked about some of the other -- some of things included there like supply disruptions, I don't know how long that's going to last. And we all know it's not just in our business, it's across all aspects of life today. And then -- it's going to go away tomorrow, it's going to go away in 12 months, not sure. That's certainly something we want to absolutely make sure that we have what we need. And so we are paying premium costs right now relative to what we did pre-pandemic to make sure our suppliers get to our patient service centers, our laboratories have everything they need. And that's really kind of our insurance, which fortunately we can afford to do right now because we also do have that COVID revenue and COVID margin.

So really, I think that's the best color I could give you, which is the base business is in good shape. We exited Q4 organically back to where we were in 2019. We've done significant M&A over the last couple of years. We've built the PLS business. So beyond the organic clinical business, we're hundreds of millions of dollars higher. And when the profitability and all that may not be precisely the same, directionally, people can feel confident that the profitability has moved with the revenue growth.

So to remind you, our base business in '21 was larger than what we had in 2019. So it has grown. So it has recovered, and we're going to grow on top of that, and that's implied in our guidance for base business. So when you intentionally broke out base business from COVID assumptions for '22, so you got to dissect going on with that business. And I keep on reminding you that these investments that we're making are part of our base business. And we've started those investments in '21. They continue to in '22, and therefore, that's going to help us accelerate growth.

And as Mark said, we feel very confident about the profitability of our base business. And by the way, what I said in my introductory remarks, is we do not believe COVID is going to entirely go away. It's going to be part of -- a permanent part of our portfolio. So you should assume there's some COVID testing in '23 as well. We will continue to play a role with our PCR testing. And we believe there's a growing role for serology, particularly related to our ability to be able to provide some insight around the protection that individuals have in their bodies, and we're going to have more on that to come. But you put it together and we believe the prospects for '23 and beyond are quite right. So thank you.

Ricky, I would add one other thing, and that's despite Mark saying that the base business has recovered to 2019 levels, there's still evidence to suggest in terms of a headwind that there's still pent-up demand for routine clinical care. If you look at the studies around HIV infection rate, hepatitis C infection rates, the data still indicates that there was a lack of routine clinical categories in pandemic, and we do think that should provide some headwinds going into the latter part of this year and next year -- (inaudible) I'm sorry.

And the next question is coming from Brian Tanquilut of Jefferies.

Congratulations all around. I guess I'll follow up to that last answer that you gave. So as we think about COVID becoming more endemic rather than what it is today, is it probably more correct to think of this opportunity or this part of your business is something like, say, the flu test where some of it -- or most of its point of care? And then a big -- small chunk of it is sent over to you guys? And then how should we be thinking about the economics, if that was the case?

Yes. Well, let me start and then my colleagues will round it out, I'm sure. So this isn't going away anytime soon. I think all of us believe that we're going to have COVID in '23, and we're going to provide testing around that. And as you know because you're living with it every day like the rest of us, when somebody has some symptoms, you're ruling out COVID. And in many cases, that is a PCR test. And that will continue. And so therefore, you don't think about just being flu, but it's any time a respiratory illness, and it could be a common cold without a respiratory illness.

So there will be a continuation of that going forward. And also, we keep on highlighting the value of serology. We think there is going to be an increased role for us to provide insight about how much protection people have from vaccines or from natural immunity. And as we know, that's changing over time, and people want to have that insight to manage the risk and work with their physician on that. So we think there there's going to be increased value in that.

So we do believe in '23, this is going to be a permanent part of our portfolio. It's hard right now to scale that, and we'll learn more as we get into '22. But when we think about it, we actually think of this as an additional portion of our product line that we didn't have before the pandemic. So we actually priced it as is helpful to achieve the value we think we have.

And then as Jim said, the base business continues to be in really strong shape. We crossed the growth of '19 sooner in '21. We're entering '22 with great momentum. Our growth prospects there continue to be ones that would continue to work. So that should continue to be a good opportunity for us. So we're feeling it fits together well, and COVID's going to provide more fuel for us to make these investments in our base business that help us in '23. So yes, we're focused on what the costs are, but we only make these investments if in fact, we expect to get the returns. And you'll see those returns both in '22, but also in '23 and beyond. So Mark, anything you'd like to add to that?

Yes. I think, Brian, it's a great question, and we can't predict with any certainty what's going to happen. I think the 2 unknowns are how comfortable will physicians be with taking the specimen sample themselves in the office going forward, and maybe they'll be very comfortable like there with the flu where maybe they'll be like, no, I'd rather not handle that. I'd rather not do that point-of-care test and all the risks that come with that. I'd rather just send it to a lab. But then the other one really importantly is the economics. So the payers are going to have a lot of influence on whether this is done.

Now yes, point-of-care testing, arguably, some people do it for faster turnaround times, but a lot of it is done because they make money off of it. So depending on what the payers decide around point-of-care reimbursement, that will have a large influence on how much of this work comes to us and how much of it stays in the office.

Yes. Then let me just add, and then I'm going to ask Jim to comment on this is, if you look at our volumes, they're impressive. We've had a challenge this year because of the infection rate, and therefore, our ability not to be able to deliver on pooling, which is more capacity at lower cost, but that will come back to detection rates drop. But as we go forward with this and we start to see this becoming more of an epidemic and less of a pandemic, then there's a lot of players in this marketplace. And Jim and his team are entirely focused on what we have for share today what we could do going forward to gain some share going forward.

So when you think about the opportunity around COVID, if you look at that market, you think about Quest Diagnostics, if you think about the dynamics of the short run, where there's been some opportunistic players, we're not opportunistic. This is going to be part of our part of our permanent -- permanent part our portfolio. And therefore, we also are pushing hard and making sure that we get what we believe we should have for share in the short term. But also in the long term, we think there might be an opportunity as well to pick up some share. Jim, do you like to add that?

Yes. What we did find during this last surge is we had a series of 10 to 12 partners that we've referred to work out to when we couldn't handle the volume, especially during peak [things] during the work. And at least 50% of those partners had gotten out of the business and decided they just didn't want to reramp our capacity. So while there may be the physical capacity out there, some of that physical capacity, especially on the PCR side, that would return to the clinical kinds of work that those firms were doing, other molecular work. So that is, I think, advantages us in the future if there is another surge.

And the next question is coming from Pito Chickering of Deutsche Bank.

Steve and Mark, it's been a pleasure working with you over the years, and congrats to you, Jim, on this promotion.

Thank you.

A lot of questions are around this base business, so let me ask this a different way. I believe you have generally blessed sort of an $8.50 EPS range for 2023 with sort of limited COVID earnings. Can you talk about EBIT margins in 2023 versus the 17% range seen in 2019 without COVID? I sort of believe sort of within that guidance range, you're implying essentially flat margins with Invigorate offsetting the inflationary pressures. Is that just the right takeaway that we should be leading today's call with?

Yes. So we intentionally don't really target or comment on margins because we believe value creation can come at different levels of margin. Then we've talked about specifically our PLS business, where it's great growth, great return on invested capital. And those are the 2 biggest correlators to shareholder value creation, but they come at a lower margin. So we don't worry about margin, Pito, per se. So -- but I understand others do.

And -- so to answer your question, there's a pretty broad range. Obviously, 1 year less than over multiple years, when you put a CAGR with a couple of hundred basis points differential on the top line and bottom line. So there's a lot of different combinations. So what I would say is your EPS number that you mentioned is not unreasonable, and you can figure out the revenue based on what we said at Investor Day and then what we're guiding to this year in terms of the base business.

And yes, at this point, we're not counting on COVID to be significantly larger than maybe a flu business or something like that. But certainly, we don't know and there's a chance that it could be larger than that, and that will be determined over the next 12 months or so. So that's about the strongest color I can give you right now is back to what we said.

We feel really good about our base business going forward. We're going to be back to that growth level. And I want to remind everybody that when we grow organically, the drop down is much higher than that 17% or the 19.5% that we delivered in Q4 and so on. It drops down at a level 50% or more, depending if it's an existing customer, where we're expanding the menu or it's a new customer where we do have to invest a little maybe in logistics and in IT for the interfaces. But growth brings with it margin expansion in addition to Invigorate, and that's why we're confident we can grow earnings faster than top line from that period forward.

Okay. So just to sort of ask the question, just a different way and not on the margin side. That means, as you sort of think about 2023 EBIT versus 2019 sort of a cleaner sort of non-COVID numbers, we should be modeling sort of a low teens EBIT increase in '23 relative to 2019?

Yes. I mean you can do the math. Yes. I mean...

What we said about our earnings per share, okay? Because what we -- Mark just said what we're saying is, we've always provided our outlook and guidance for our mix our share because we do have a mix of business. And we do have some lower-margin business that might be a good value-creating opportunity for us and we're going to go after it like our PLS business. So I think the best guide to look at EPS or the expansion of EPS over time, rebasing, if you will, for these changes that we've seen through the last 2 years. And Mark has reiterated our belief that our base business will fuel good opportunities for us to continue to deliver against that. And by the way, as we continue to gain share, the variable gross margin is quite good. And as I said, we also believe there's going to be some COVID in '23, and it's hard to size it right now, but it's not going to go away anytime soon.

Yes. And the other thing is too, I mean, you know, I'm not in a position to provide guidance of 2023. So that's why we're focusing everyone on the base business. However, when you think about what could happen, COVID can be larger. We don't know. We're not counting at this point. And then we did mention we've got a -- we expect to have $1 billion of cash this year. So between opportunities do quite a bit of M&A, and we'll see or do share repurchases, those also aren't specifically contemplated.

So that's why like locking down to a specific number, is really difficult and probably not productive. So I would point you to what we said at our Investor Day and kind of assuming that, that's reasonable if these things don't play out significantly differently from our current view of what 2023 might bring.

And the next question is coming from Matt Larew of William Blair.

The 3% Invigorate target has been aided in recent years as you've consolidated a volume onto your 2 new labs and consolidated under one amino acid platform. I'm curious what are the keys going forward here to keep driving those gains? And then maybe the second piece on costs would be separate from some of the extra costs you've called out today related to COVID. Clearly, you've built up some infrastructure, both personnel and instrumentation for COVID. I'm just curious how much of that do you think goes away as COVID moves to an endemic and perhaps you need less extra capacity?

Great. Thanks for the question. I'll start and then turn to Jim to add to it. But -- we've been working on operational excellence for over a decade, and it has become institutionalized in our company culture and embedded now as we do things. And it is a platform for us and we're going to continue to grow. So your comment is around cost. I mean we don't talk about costs. We talked about productivity. Because there's a lot of aspects of what we do around Invigorate and some actually helps the topline, some actually helps getting more output with less labor. And yes, some helps us become more efficient by less input from some of the materials that we use. So we look at it as an aggregate.

And we continue to be bullish on our prospects. We believe that it is the ingredients for us to continue to deliver great value. That is when we do this, we improve our quality, our service gets better. By the way, we become more and more productive to be able to make investments to fuel the growth. It all fits together. And then when we talk about this and we've talked about at Investor Day, we see an enormous opportunity for us to continue to digitize and innovate in operational excellence. And so some of you have had the opportunity to tour through our latest lab of the future, and that's our new facilities, facility in Clifton, New Jersey. And sometimes if you come in, you'll see what we've done, you would take some of the learning out of our Marlborough facility up in the Boston area. We brought that down to the Clifton, that we built on it. And that also uses the advantages of some consolidation with some of our new platforms.

But Jim and the team are now taking that and thinking about, okay, what's next, okay? So when you think about innovation in our space, yes, there's innovation in terms of testing and as far as Diagnostic Information Services, but we equally think there's a lot of innovation and opportunity for us to move forward. So we continue to invest. And when you talk about investments, we talk about the use of cash. As you noticed, we've been putting about $400 million a year into our capital budget, which is investments and frankly, a lot of our innovation that allow us to fuel this productivity gain. So Jim, add to that, please.

Yes. I think Steve touched on the 3 key things, automation; the use of artificial intelligence; and then the continued digitization of so many attainable processes. So Marlborough and Clifton are terrific examples of that. But as you know, they're all brand-new laboratories. We've got 20-plus other laboratories in our network, and there's opportunities in every one of those laboratories without building new greenfield sites to continue that automation journey. In particular, in our specimen processing area in what we call our fluid handling system, handling a blood in urine. On the artificial intelligence side, you're going to see us move in pathology, psychology, microbiology. We've got some great examples in each of those departments today. we're deploying artificial intelligence systems to help with the readout of those images.

And then as Steve mentioned, just the continued digitization. Now beyond the immunoassay platform where we consolidated around the Atellica, there are still other opportunities like that in our laboratories. We recently ran a competition in urinalysis selected the new vendors, Sysmex for that platform and rolling out those new platforms across all 23-plus laboratories is going to generate a lot of productivity year-over-year. So as long as we have healthy third-party vendors that continue to innovate, those innovations will come to our labs, and we'll continue along that 3% productivity journey.

Yes. So we're bullish on the prospects of continuing to drive productivity. I always react to -- this is a cost-cutting goal. And this is not about cost-cutting goal, this is about working smarter. And this has been a key part of our strategy, and it fuels growth. And Jim mentioned some of the areas. I mentioned in my introductory comment also digital pathology which will revolutionize our ability to diagnose and treat and to do that more productively. And as, this week, Jim is going out to another laboratory, taking a look at where we're going to make our next investment this year. So we're going to continue to invest in this space, and we think there's more opportunity in front of us. So it's exciting.

Yes. I just want to add that, remember, this is not just in the lab, so there's a lot of productivity that's driven outside and, specifically, I'll give 2 examples of logistics. So we really have an incredible ability to be efficient with logistics and it's continuing to improve. So we have some cases where we have empty pickups where we have some customers that don't give us specimens all the time. It's periodic. Now we have the ability and technology to not do that empty pickup.

So that's an efficiency. We also get requests for what we call stack pickups, where somebody needs something quick turnaround, et cetera. And so the ability to most efficiently get one of our vehicles there has been enhanced in our technology. The other one is in our patient draw centers. We really increasingly move the administrative burdens off the phlebotomist, allow them to do phlebotomy by getting people to go to our website, put in their insurance information, everything.

And so a phlebotomist can spend a couple of less minutes with each patient doing administrative work, doing phlebotomy. We drive up the productivity in our draw center. So those are just a couple of examples of productivity gains that aren't really cost reductions, but enhance our ability to do more with the same resources and drive up our quality and everything else outside the laboratory.

The next question is coming from Tycho Peterson of JPMorgan.

This is Casey on for Tycho. Congratulations to all. Can you maybe talk towards the percentage of COVID testing that was consumer initiated in 4Q, whether through MyQuest direct or other non-traditional avenues? And how do you see that trending in 2022? You mentioned that there are different costs associated with non-traditional avenues of testing. So maybe can you quantify the difference in margin profiles between traditional and nontraditional.

Yes. So what I can share is, go back to what we said in the prepared remarks, our consumer business was about $70 million last year between the base and COVID. We did $2.7 billion of COVID revenue. So the consumer-initiated COVID testing was very small at this point. And it's strengthening. And again, as I said, we continue to enhance our website when people go for that ordering and testing and so on. But there's still more to come in terms of enhancing that experience for consumers and maybe in driving awareness for people.

As you know, we're competing with a lot of people who see these standup operations in parking lots and so on and so forth, which draw their attention. So we're working on making sure that they know we can do this if they initiate themselves as opposed to going to a doctor or a hospital for this, and we expect to get stronger and stronger moving forward as we enhance our overall consumer business because of these investments we just mentioned.

In terms of the margin profile, it's really not -- it's not all that different between the consumer. And consumer can have it in different ways. They can come to our patient draw center and have it done there. We do have home collection kits where they can be sent to their home. So a little different structure, but not materially different in profitability.

And the next question is coming from Derik De Bruin of Bank of America.

Can we talk a little bit about sort of like the real -- the PAMA outlook. So you would assume $80 million hit again in -- comes back in '23. I mean, what are the chances that this actually does get resolved and that the lobbying efforts pay off? I mean is the current administration a little bit more and Congress a little bit more willing to sort of listen to this and sort of do with it? I mean, is there any chance that it gets that there's actually some reversion, just given what happened?

Yes. Before Steve addresses that, I just want to remind everybody that, that $80 million was built into our long-term outlook. We just assumed it would happen this year. So again, although it will be a year-on-year hit to us, incrementally in comparison in the long-term outlook, it was assumed that we would get that in 2022. So it's already filled in. Go ahead, Steve.

Yes. So thanks for the question. And as we said, we were thankful that it was delayed. Again, the 1-year offset, as Mark indicated, to '23. We think that's good for us because it will gain us some time this year to keep on working on a permanent fix with Congress. And we have been very active working with Congress last year. And as you know, Congress was very busy with the infrastructure bill and other business. And therefore, we were fortunate enough to get in the postponement of PAMA, but it allows us time this year if they keep on working on this to get a COVID effects. And we're encouraged by the level of support. The good news about pandemic is, it brought for us, the importance of testing, the importance of having a strong industry.

We're getting strong, the bipartisan support, both from the House and from the Senate. We made a proposal of what we think should be changed to improve the data collection process, the sampling of market-based data. We continue to support the notion and the philosophy of PAMA that is we should be paid in commercial rates, but we believe that CMS cut it wrong.

And in parallel with the work we're doing with Congress, we continue to have our lawsuit against CMS as a trade association, the judge has sort of the arguments. We'll see if we get some indication on the decision on that, hard to call that, but that still in the works as well. So our work, right now, this year, is to push for permanent fix to PAMA and we're better positioned now because of pandemic than before the pandemic because of the strength of this industry and full awareness and appreciation of what we've done and the need for a strong laboratory industry going forward.

Our last question is coming from Eric Coldwell of Baird.

Masterful job, clearing up some of the overriding concerns on core market today. When you went through your list of things that don't repeat or go down significantly as COVID incremental cost over time, staffing challenges, et cetera, go away. You mentioned bonuses. And I think it was the one number and the list of call-outs that I didn't hear you quantify. I'm curious if we could get the incremental bonus due to the COVID upside profitability in '21, how you think that bonus will normalize, whether it's '22 or '23?

And then my follow-up, I'll just throw it in here. I was hoping we could get average weighted reimbursement in the fourth quarter. I know you said it would be relatively similar through the PHE, but if you could give us a little more specificity on where AWR came out in 4Q on COVID PCR testing? That would be helpful.

Sure. So let me start with that one because I think there were some questions around maybe whether turnaround time suffered and we didn't get the $25 fee that comes with some of the government payers, a couple of the commercial payers. And actually, not really. AWR in Q4 was absolutely similar to what it has been in the previous quarters and our turnaround-time performance was outstanding. We did in January when the search came. We did a little bit -- we did have a little bit of a hit to our turnaround time. But obviously, that's all contemplated in the guidance that we just provided in everything. It wasn't a huge amount. When you go back to the earlier question...

Bonuses.

And the bonuses. When you look at the bonuses, most of that is really our 50,000 employees. So people think about, bonuses must be for senior management. But most of the cost is really -- we paid 3% bonus to even our wage workers. And then obviously, we have other staff members that have higher targets. And every year, we budget for what we call 1x, whatever that target is. So for most of the people, it would be 3%. And based on performance, and we feel we've had reasonably stretched performances when you list historically, we have not paid significantly above 1x, and we've had a number of years where it's below 1x.

But in the COVID unpredictability and the surge in revenues enabled us to pay our employees significant bonuses in 2020 and again in 2021. And so if you look at -- without getting too specific, we've shared a number in the past of $3 billion wage bill, that's gone up in the last couple of years as we've grown the company. So you can kind of, as a floor, say, 3%, obviously, a little higher because there's people on higher bonus, that's about 1x. And then we're paying a bonus that's substantially higher than that in 2021, like we did in 2020. The other thing is we did pay out a $500 payment to majority of our employees to compensate them for COVID expenses.

In 2020, we adjusted it out of our adjusted earnings because we were seeing COVID as temporal and extraordinary. But once you get to your second time doing it, even though I think -- I still think it's extraordinary, we just decided not to adjust it out. So we did have over $20 million payments late in the year, $500 to our wage employees and some of our lower compensated professionals as well. So those are a couple of things that would go away and not be repeated unless somehow, we had another surprising COVID year in 2022, like we had in 2021.

Great response. I'm not sure I'm smart enough to do 1x, 3% plus and then significant increases there. Is there any chance you could frame that as a incremental $50 million, incremental $100 million? And just directionally, can we get a little closer?

Yes, let's say, it's less than $100 million, but substantially more than $50 million.

Okay. That's about what I thought. Okay. Congrats to everyone.

We done?

Yes.

Very good. Well, thanks. It's been a good session with you all. Thanks for all the great questions. And again, thanks for joining the call today, and we appreciate your support. You guys have a great day.

Thank you for participating in the Quest Diagnostics Fourth Quarter and Full Year 2021 Conference Call. A transcript of our prepared remarks on this call will be posted later today on the Quest Diagnostics' website at www.questdiagnostics.com. A replay of the call may be accessed online at www.questdiagnostics.com/investor or by phone at 1 (800) 839-9317 for domestic callers or (203) 369-3605 for international callers. Telephone replays will be available for approximately 10:30 a.m. Eastern Time on February 3 until midnight Eastern Time, February 17, 2022. Goodbye.