Encompass Health Corp (EHC) 2023 Q4 法說會逐字稿

Good morning, everyone, and welcome to Encompass Health's Fourth Quarter 2023 Earnings Conference Call. (Operator Instructions)

大家早安，歡迎參加 Encompass Health 2023 年第四季財報電話會議。 （操作員說明）

Today's conference call is being recorded. If you have any objections, you may disconnect at this time.

今天的電話會議正在錄音。如果您有任何異議，您可以此時斷開連接。

I'll now turn the call over to Mark Miller, Encompass Health's Chief Investor Relations Officer.

我現在將把電話轉給 Encompass Health 首席投資者關係長 Mark Miller。

Thank you, operator, and good morning, everyone. Thank you for joining Encompass Health's Fourth Quarter 2023 Earnings Call. Before we begin, if you do not already have a copy, the fourth quarter earnings release, supplemental information and related Form 8-K filed with the SEC are available on our website at encompasshealth.com.

謝謝接線員，大家早安。感謝您參加 Encompass Health 的 2023 年第四季財報電話會議。在我們開始之前，如果您還沒有副本，請在我們的網站 enconcepthealth.com 上獲取向 SEC 提交的第四季度收益發布、補充資訊和相關 8-K 表格。

On Page 2 of the supplemental information, you will find the safe harbor statements, which are also set forth in greater detail on the last page of the earnings release. During the call, we will make forward-looking statements, which are subject to risks and uncertainties many of which are beyond our control. Certain risks and uncertainties, like those relating to regulatory developments as well as volume, bad debt and labor cost trends that could cause actual results to differ materially from our projections, estimates and expectations are discussed in the company's SEC filings, including the earnings release and related Form 8-K, and the Form 10-K for the year ended December 31, 2023, when filed.

在補充資料的第二頁上，您將找到安全港聲明，這些聲明也在收益發布的最後一頁上有更詳細的說明。在電話會議期間，我們將做出前瞻性陳述，這些陳述受到風險和不確定性的影響，其中許多風險和不確定性是我們無法控制的。某些風險和不確定性，例如與監管發展以及數量、壞帳和勞動成本趨勢相關的風險和不確定性，可能導致實際結果與我們的預測、估計和預期有重大差異，這些風險和不確定性在公司向SEC 提交的文件中進行了討論，包括收益報告和報告。提交時截至 2023 年 12 月 31 日的相關表格 8-K 和表格 10-K。

We encourage you to read them. You are cautioned not to place undue reliance on the estimates, projections, guidance and other forward-looking information presented, which are based on current estimates of future events and speak only as of today. We do not undertake a duty to update these forward-looking statements. On the supplemental information -- our supplemental information and discussion on this call will include certain non-GAAP financial measures. For such measures, reconciliation to the most directly comparable GAAP measure is available at the end of the supplemental information, at the end of the earnings release and as part of the Form 8-K filed yesterday with the SEC, all of which are available on our website.

我們鼓勵您閱讀它們。請注意，不要過度依賴所提供的估計、預測、指導和其他前瞻性信息，這些信息基於對未來事件的當前估計，並且僅代表今天的情況。我們不承擔更新這些前瞻性陳述的責任。關於補充資訊－我們在本次電話會議上的補充資訊和討論將包括某些非公認會計準則財務指標。對於此類指標，可在補充資料末尾、收益發布末尾以及昨天向 SEC 提交的 8-K 表格中找到與最直接可比較的 GAAP 指標的對賬，所有這些均可在我們的網站。

(Operator Instructions) With that, I'll turn the call over to Mark Tarr, Encompass Health's President and Chief Executive Officer.

（操作員指示）接下來，我將把電話轉給 Encompass Health 總裁兼執行長 Mark Tarr。

Thank you, Mark, and good morning, everyone. The fourth quarter was a strong finish to a great 2023 for our company. I'll discuss key highlights for the year, and then Doug will provide details about our Q4 results and 2024 guidance.

謝謝你，馬克，大家早安。第四季為我們公司的 2023 年輝煌畫上了圓滿的句號。我將討論今年的主要亮點，然後 Doug 將提供有關我們第四季度業績和 2024 年指導的詳細資訊。

Our 2023 revenue increased 10.4%, driven by strong volume growth with total discharges up 8.7%, inclusive of same-store growth of 4.8%. Our strong volume growth continues to provide evidence that our value proposition is resonating with referral sources, payers and patients. Our 2023 adjusted EBITDA increased 18.5%, driven by revenue growth and prudent expense management.

在銷售強勁成長的推動下，我們 2023 年的營收成長了 10.4%，總銷量成長 8.7%，其中同店成長 4.8%。我們強勁的銷售成長繼續證明我們的價值主張與轉診來源、付款人和患者產生共鳴。在營收成長和審慎費用管理的推動下，我們的 2023 年調整後 EBITDA 成長了 18.5%。

Persistent vigilance on premium labor utilization facilitated a 32.9% decrease in contract labor plus sign-on and shift bonuses. On a dollar basis, these premium labor expenses decreased $67.3 million from $204.3 million in 2022 to $137 million in 2023. We reduced contract labor FTEs from an average of 547 in 2022 to 425 in 2023 and contract labor FTEs as a percent of total FTEs from an average of 2.2% to 1.6% over the same period. Other operating expenses as a percent of revenue declined by 50 basis points from 15.3% to 14.8%, owing in part to scale efficiencies. The strong growth in adjusted EBITDA facilitated an adjusted free cash flow increase of 54.6% to $525.7 million.

對優質勞動力利用率的持續警覺導致合約工加上簽約和輪班獎金減少了 32.9%。以美元計算，這些優質勞動力費用從2022 年的2.043 億美元減少到2023 年的1.37 億美元，減少了6730 萬美元。我們將合約工FTE 人數從2022 年的平均547 人減少到2023 年的425 人，合約工FTE 佔FTE 總數的百分比從同期平均成長2.2%至1.6%。其他營運費用佔收入的百分比下降了 50 個基點，從 15.3% 降至 14.8%，部分原因是規模效率。調整後 EBITDA 的強勁成長推動調整後自由現金流成長 54.6%，達到 5.257 億美元。

We continue to invest in capacity expansion to meet the needs of a significantly underserved and growing market for inpatient rehabilitation services. In 2023, we invested more than $350 million in growth CapEx, opening 8 de novos with a total of 395 beds and adding 46 beds to existing hospitals, a net 4.1% increase in licensed beds.

我們持續投資於產能擴張，以滿足服務嚴重不足且不斷成長的住院復健服務市場的需求。 2023年，我們投資超過3.5億美元用於成長資本支出，從頭開設8家醫院，總共395張床位，並向現有醫院增加46張床位，許可床位淨增加4.1%。

We also continue to invest in our facility-based technology through initiatives like our Tablo on-site dialysis rollout. We now offer in-house dialysis capabilities in 83 of our hospitals and we'll continue the rollout to new locations in 2024. We complemented these investments in the growth of our business with a return of approximately $60 million to our shareholders through cash dividends on our common stock. Our strong free cash flow generation allowed us to fund these investments and shareholder distributions with internally-generated funds, all while reducing our net leverage to 2.7x at year-end 2023 from 3.4x at the end of 2022.

我們也透過推出 Tablo 現場透析等措施繼續投資於基於設施的技術。我們現在在 83 家醫院提供內部透析能力，並將於 2024 年繼續在新地點推廣。我們透過現金股利為股東帶來約 6,000 萬美元的回報，補充了這些投資對我們業務成長的影響。我們的普通股。我們強大的自由現金流產生使我們能夠用內部產生的資金為這些投資和股東分配提供資金，同時將我們的淨槓桿率從 2022 年底的 3.4 倍降至 2023 年底的 2.7 倍。

Review Choice Demonstration or RCD began on August 21 in Alabama. Our company was well prepared to address the administrative requirements of this program. Recall that under RCD, every Medicare claim is reviewed for documentation and medical necessity. The affirmation rate targets set by CMS under RCD is 80% of claims submitted during the first 6 months of our affirmation rate remains above that level.

審查選擇示範（RCD）於 8 月 21 日在阿拉巴馬州開始。我們公司已做好充分準備來滿足該計劃的管理要求。回想一下，根據 RCD，每項 Medicare 索賠都會經過文件記錄和醫療必要性審查。 CMS 在 RCD 下設定的確認率目標是前 6 個月內提交的索賠的 80%，我們的確認率仍然高於該水準。

Turning to objectives for 2024. We continue to build and maintain an active pipeline of de novo projects, both wholly owned and joint ventures with acute care hospitals. We expect to open 6 de novos in 2024 as well as a 40-bed freestanding hospital licensed as a satellite location on an existing hospital that will be accounted for as a bed addition. To date, we've announced an additional 11 de novos with opening dates beyond 2024. We anticipate adding approximately 150 beds to existing hospitals in 2024, including the aforementioned satellite and 80 to 120 beds per year from 2025 through 2027.

談到 2024 年的目標。我們繼續建立和維護一系列活躍的從頭項目，包括獨資項目和與急診醫院的合資項目。我們預計將在 2024 年重新開設 6 家醫院，以及一家擁有 40 個床位的獨立醫院，該醫院將作為現有醫院的衛星位置獲得許可，並將計入床位增加。迄今為止，我們已宣布新增11 個新醫院，開業日期將在2024 年之後。我們預計在2024 年為現有醫院增加約150 個床位，其中包括上述附屬醫院，並從2025 年到2027 年每年增加80 至120 個床位。

We continue to focus on enhancing patient outcomes by investing resources and clinical innovations. One such innovation is our fall prevention model, which combines predictive modeling with our core clinical practice protocols. Our fall prevention model was initiated in 2021, and we have since seen our fall rates per 1,000 patient days improved 24%. We have an array of additional clinical innovations and enhancements underway, which are intended to advance our ability to consistently produce quality outcomes for medically-complex high-acuity patients in need of inpatient rehabilitation care.

我們持續致力於透過投資資源和臨床創新來提高患者的治療效果。其中一項創新是我們的跌倒預防模型，它將預測模型與我們的核心臨床實踐方案結合。我們的跌倒預防模式於 2021 年啟動，此後我們發現每 1,000 個患者日的跌倒率提高了 24%。我們正在進行一系列額外的臨床創新和改進，旨在提高我們為需要住院復健護理的醫療複雜高風險患者持續提供高品質結果的能力。

Now I'll turn it over to Doug.

現在我把它交給道格。

Thank you, Mark, and good morning, everyone. As Mark stated, Q4 was a strong finish to 2023. Revenue for the quarter increased 9.6% over the prior year, driven primarily by volume growth. Total discharges grew 8.3%, inclusive of 5.3% same-store growth. Volume strength was broad-based across geographies and patient mix and exceeded our expectations.

謝謝你，馬克，大家早安。正如 Mark 所說，第四季是 2023 年的強勁收官。該季度的營收比上一年增長 9.6%，這主要是由銷量成長推動的。總銷售額成長 8.3%，其中同店成長 5.3%。銷售強度​​在各個地區和患者組合中具有廣泛的基礎，並且超出了我們的預期。

Q4 adjusted EBITDA also increased 9.6% over the prior year as the contribution from increased volume and favorable operating expenses was partially offset by an incremental bad debt reserve. Our 2023 de novos outperformed in Q4, generating approximately $1 million in adjusted EBITDA compared to our expectation of approximately $2.5 million to $4.5 million of net preopening and ramp-up costs. The favorable performance relative to our expectations was driven primarily by the joint venture de novos.

第四季調整後 EBITDA 也較上年增長 9.6%，因為銷售量增加和有利的營運費用的貢獻被增量壞帳準備金部分抵銷。我們 2023 年的 de novos 在第四季度表現出色，調整後 EBITDA 產生約 100 萬美元，而我們預計開業前和啟動成本約為 250 萬至 450 萬美元。相對於我們預期的良好業績主要是由合資企業 de novos 推動的。

For the full year of 2023, our de novo net preopening and ramp-up costs were $6.6 million. Within our 2024 guidance considerations, we are anticipating $15 million to $18 million of de novo net preopening and ramp-up costs. The year-over-year difference is largely attributable to the timing of new hospital openings and the balance between joint venture and wholly owned de novos.

2023 年全年，我們的重新開業和啟動淨成本為 660 萬美元。在我們的 2024 年指導考慮範圍內，我們預計新的淨預開放和提升成本將達到 1500 萬至 1800 萬美元。同比差異主要歸因於新醫院開業的時間以及合資醫院和獨資醫院之間的平衡。

We continue to see improvement in year-over-year premium labor costs. Q4 contract labor plus sign-on and ship bonuses totaled $30.6 million compared to $35.4 million last year. Within premium labor costs, Q4 contract labor was $17.7 million and sign-on and shift bonuses were $12.9 million as compared to $19.7 million and $15.7 million in Q4 of 2022. On a sequential basis, premium labor decreased by $2.7 million.

我們繼續看到優質勞動成本較去年同期有所改善。第四季合約工加上簽約和發貨獎金總計 3,060 萬美元，而去年為 3,540 萬美元。在優質勞動成本中，第四季合約勞動力為1,770 萬美元，簽約和輪班獎金為1,290 萬美元，而2022 年第四季為1,970 萬美元和1,570 萬美元。按順序計算，優質勞動力減少了270 萬美元。

Our Q4 adjusted EBITDA included approximately $6.8 million in favorable reserve adjustments for workers' comp and general professional liability insurance. On a full year basis, 2023 included approximately $11.2 million in favorable reserve adjustments for these self-insured programs. These reserve adjustments are out of period as they relate to claims prior to 2023. Our Q4 adjusted EBITDA also benefited from favorable trends in group medical claims under our self-insured program.

我們在第四季度調整後的 EBITDA 包括約 680 萬美元的工人補償和一般專業責任保險的有利準備金調整。從全年來看，2023 年為這些自我保險計劃提供了約 1,120 萬美元的有利準備金調整。這些準備金調整已過時，因為它們與 2023 年之前的索賠相關。我們第四季度調整後的 EBITDA 也受益於我們自我保險計劃下團體醫療索賠的有利趨勢。

Q4 revenue reserves related to bad debt as a percent of revenue increased 170 basis points to 4.1% as a result of an approximately $22 million reserve related to appeals pending before the Departmental Appeals Board and various federal district courts. These appeals relate to claims denied primarily prior to 2018 and under review programs that are different from TPE and RCD. We now have a full year of experience at the Departmental Appeals Board and have updated our reserve assumptions given our experience to date.

第四季與壞帳相關的收入準備金佔收入的百分比增加了 170 個基點，達到 4.1%，原因是與部門上訴委員會和各聯邦地區法院待決上訴相關的準備金約為 2,200 萬美元。這些上訴涉及主要在 2018 年之前被拒絕的索賠，並且正在接受與 TPE 和 RCD 不同的審查計劃。我們現在在部門上訴委員會擁有一整年的經驗，並根據迄今為止的經驗更新了我們的準備金假設。

After giving effect to minority interest, the Q4 adjusted EBITDA impact of this incremental bad debt reserve was approximately $16 million. Adjusted free cash flow for the quarter increased 103.3% to $93.5 million due to higher adjusted EBITDA, lower maintenance CapEx and favorable changes in working capital.

少數股東權益生效後，此一增量壞帳準備金對第四季調整後 EBITDA 的影響約為 1,600 萬美元。由於調整後 EBITDA 較高、維護資本支出較低以及營運資本的有利變化，本季調整後自由現金流成長 103.3% 至 9,350 萬美元。

Moving on to guidance. Our 2024 guidance includes net operating revenue of $5.2 billion to $5.3 billion, adjusted EBITDA of $1.015 billion to $1.055 billion, and adjusted earnings per share of $3.77 to $4.06. The key considerations underlying our guidance can be found on Page 13 of the supplemental slides.

繼續指導。我們的 2024 年指引包括淨營業收入 52 億美元至 53 億美元，調整後 EBITDA 10.15 億美元至 10.55 億美元，調整後每股收益 3.77 美元至 4.06 美元。我們的指導背後的關鍵考慮因素可以在補充幻燈片的第 13 頁找到。

With that, we'll open the line for Q&A.

這樣，我們將開通問答熱線。

(Operator Instructions) And we'll take our first question today from Kevin Fischbeck with Bank of America.

（操作員說明）今天我們將回答美國銀行的 Kevin Fischbeck 提出的第一個問題。

Actually, this is Joanna filling for Kevin today. Yes. There's too many -- too many things going on at the same time. So we've got to do this way.

事實上，這是喬安娜今天替凱文做的事。是的。有太多太多的事情同時發生。所以我們必須這樣做。

So I guess my question around volumes, because clearly, you highlighted volumes also came in better than your internal expectations and obviously, very robust growth year-over-year. So I guess the question is, is that sustainable? What do you assume for same-store volumes growth in 2024 guidance?

所以我想我的問題是關於銷量的，因為顯然，您強調的銷量也好於您的內部預期，而且顯然，同比增長非常強勁。所以我想問題是，這是可持續的嗎？您對 2024 年同店銷售成長的指引有何假設？

And I guess I understand you mentioned that the strength was broad-based geographically. But can you talk about maybe whether there was any category that stood out or maybe the payer as well and flu, I guess, or any impacts kind of seasonal in Q4?

我想我明白你提到這種優勢有廣泛的地理基礎。但您能否談談是否有任何類別脫穎而出，或者付款人以及流感，我猜，或者第四季度的任何季節性影響？

Joanna, this is Mark. I'll take a shot at this first. We -- as you noted, we saw a nice volume growth across all 8 of our geographic regions. And we -- I think there's a number of things. One, we continue to see where we have taken market share from nursing homes. I think that going back to last 2 or 3 years, we've proven ourselves very capable of taking a higher acuity patient and having great outcomes with them. So that is -- has been a primary driver to us.

喬安娜，這是馬克。我會先試試看。正如您所指出的，我們在所有 8 個地理區域都看到了良好的銷售成長。我認為有很多事情。第一，我們持續關注從療養院奪取的市場份額。我認為，回顧過去的兩三年，我們已經證明自己非常有能力接受更高敏銳度的患者，並為他們帶來良好的結果。所以這一直是我們的主要驅動力。

I think that it's no secret that the acute care hospitals have seemed to had strong volumes, which we get the downstream impact from that. Relative to program mix, it was another quarter of continued growth in our stroke program and other neurological conditions. We did see some pickup on a small base in our orthopedic categories. But nonetheless, we did see a percentage increase in lower extremity joint placements and other orthopedic as well. So it was very broad-based in terms of our overall growth, and we're confident that we're building a good foundation.

我認為，急診醫院的治療量似乎很大，這已經不是什麼秘密了，我們從中得到了下游影響。相對於計畫組合，我們的中風計畫和其他神經系統疾病又持續成長了四分之一。我們確實看到我們的骨科類別在小範圍內出現了一些回升。但儘管如此，我們確實看到下肢關節置換和其他骨科手術的百分比增加。因此，就我們的整體成長而言，這是非常廣泛的，我們相信我們正在建立良好的基礎。

Just to add a couple of other things to round out your question. In terms of the expectations for volume growth in 2024, if you kind of parse through the guidance considerations, you get a range of the discharge growth that is kind of in line with our longer-term target of 6% to 8%, obviously coming off a number of strong years. The low end of the range would be slightly above that but the rest of the range is solidly within that.

只是添加一些其他內容來完善您的問題。就 2024 年銷售成長的預期而言，如果您仔細分析指導考慮因素，您會得到一系列排放量增長，這與我們 6% 至 8% 的長期目標相符，顯然即將到來度過了一些強勁的年份。該範圍的下限將略高於該範圍，但該範圍的其餘部分則穩定在該範圍內。

In terms of the breakdown between same-store and new store, we obviously have the 8 units that we opened this year that will be a new store. And so that's a bit of a tailwind there. And it's worth recognizing that if you look at the 4-year CAGR in same-store growth that extends from 2019 to 2023, that's north of 5%. So we continue to demonstrate very positive numbers there. But it's not to suggest that we're going to be in a position to generate 5% same-store growth on a year-over-year basis. There will be some fluctuations from year-to-year.

從同店和新店的細分來看，我們今年新開的8家顯然是新店。所以這有點順風順水。值得認識到的是，如果你看看從 2019 年到 2023 年同店成長的 4 年複合年增長率，你會發現這一數字超過了 5%。因此，我們繼續在那裡展示非常積極的數字。但這並不意味著我們能夠實現 5% 的同店年成長。每年都會有一些波動。

The patient mix was very broad-based, as Mark mentioned. We did continue to see outsized growth in some of the smaller categories like ortho, but saw in excess of 5% growth in neurological and just about 5% growth in stroke. So those are good numbers.

正如馬克所提到的，患者組合非常廣泛。我們確實繼續看到一些較小類別（例如骨科疾病）的大幅增長，但神經系統疾病的增長超過 5%，中風疾病的增長僅為 5% 左右。所以這些都是不錯的數字。

And then finally, as it relates to payer mix. On a year-over-year basis, we saw the Medicare Advantage payer mix increase by 90 basis points. But importantly, about 50 basis points of that growth came out of general managed care and another 20 or 30 basis points came out of Medicaid. So those were both representing a positive trade out of our lowest reimbursement categories into a higher reimbursement category.

最後，因為它與付款人組合有關。與去年同期相比，我們看到 Medicare Advantage 付款人組合增加了 90 個基點。但重要的是，大約 50 個基點的成長來自一般管理式醫療，另外 20 或 30 個基點來自醫療補助。因此，這些都代表著從最低報銷類別到更高報銷類別的積極交易。

Next, we'll hear from Pito Chickering with Deutsche Bank.

接下來，我們將聽取德意志銀行 Pito Chickering 的發言。

You've actually got Kieran Ryan on here for Pito, same idea as Joanna earlier, lots of calls. I wanted to ask on margins. It looks like the guidance is implying about 50 bps of year-over-year contraction on your reported 2023 figures, maybe a little bit less than that when adjusting for the reserve, the benefits and the de novo outperformance.

事實上，基蘭·瑞安（Kieran Ryan）在這裡為皮托服務，與喬安娜之前的想法相同，有很多電話。我想問一下邊緣。看來該指引意味著您報告的 2023 年數據將同比收縮約 50 個基點，可能比調整準備金、收益和新表現時的收縮幅度要小一些。

But just broadly, when we think about what could drive margins lower year-over-year, how should we think about these headwinds from labor and the de novos compared to the fixed cost leverage that you should get on this very strong volume growth you're seeing?

但從廣義上講，當我們考慮什麼可能導致利潤率逐年下降時，與您應該在如此強勁的銷售成長中獲得的固定成本槓桿相比，我們應該如何考慮來自勞動力和從頭開始的這些阻力？重新看到？

Well, Kieran, I think you hit exactly on it, which is we've got all in and assume 4% to 5% increase in SWB per FTE. And so what's driving that is an assumed 4% to 5% increase in general internal SW per FTE and then the benefits of getting some leverage with volume growth across assumed relatively constant premium labor cost is being offset by an increase and benefits cost, which is largely attributable to the fact that we had such a favorable outcome this year. And so that next to the 4% to 5% for an SWB increase.

好吧，Kieran，我想你說得對，我們已經全力以赴，假設每 FTE 的 SWB 增加 4% 到 5%。因此，推動這一趨勢的因素是假設每FTE 的一般內部軟體增加4% 至5%，然後在假設相對恆定的優質勞動力成本下通過數量增長獲得一定槓桿的好處將被增加的福利成本所抵消，即很大程度上歸功於我們今年取得如此好的成績。因此，SWB 增加了 4% 到 5%。

And then it's a pretty significant swing going from a little over $6 million in net preopening costs for 2023 to assume $15 million to $18 million in 2024. And that's got a number of factors implied in it. In 2023, we had a much heavier weighting towards the first half of the year in terms of openings, and we're anticipating for 2024. And 5 of the 8 facilities that opened in 2023 were joint ventures, including a couple of those that were with existing joint venture partners. So those ramped faster than the balance that we're anticipating in 2024.

然後，從 2023 年開業前的淨成本略高於 600 萬美元到 2024 年的 1500 萬美元到 1800 萬美元，這是一個相當大的波動。這其中隱含著許多因素。 2023 年，我們在上半年開業方面的權重要大得多，我們預計 2024 年。2023 年開業的 8 家工廠中有 5 家是合資企業，其中包括幾家合資企業。與現有的合資夥伴。因此，這些成長速度快於我們預期 2024 年的平衡。

But those are the 2 primary factors that could create a little bit of rub on the margin. And as we have said repeatedly, we are an EBITDA and an EBITDA growth story. We are not necessarily a margin story. We'll always seek to gain leverage as we're growing volume. But the most important thing that we can do is get out there and provide extremely high-quality care to more patients who are in need of inpatient rehabilitative services, and we continue to believe that the market is underserved.

但這是可能對利潤造成一點摩擦的兩個主要因素。正如我們一再說過的，我們是一個 EBITDA 和一個 EBITDA 成長的故事。我們不一定是邊緣故事。隨著銷量的成長，我們將始終尋求獲得影響力。但我們能做的最重要的事情是走出去，為更多需要住院復健服務的患者提供極其高品質的護理，而且我們仍然認為市場服務不足。

Appreciate that. And then just a quick follow-up on the labor side, 55 net RN hires in 4Q, solid, obviously, down a bit from the last 2 quarters where you're up in the 200 range. But should we think about this as kind of the right pace as to what you're targeting heading into '24, given where volumes are running and that you've already cut down contract labor down to that 1.5%, 1.4% of FTEs? Or do you see it accelerating further from here?

感謝。然後，在勞動力方面進行快速跟進，第四季度淨招聘 55 名註冊護士，顯然，比過去兩個季度的 200 人有所下降。但是，考慮到產量的增長情況以及您已經將合約工削減至 FTE 的 1.5%、1.4%，我們是否應該將此視為您進入 24 世紀的目標的正確步伐？或者你認為它會進一步加速嗎？

We're actually very pleased with that number in Q4. If you look back at prior year, that was a negative net. And if you think about the period of the year that's extremely difficult to hire new staff it's around the holidays and particularly in Q4. So our Town acquisition team has been very successful in helping to support the hospitals as well as the new ramp-ups and finding and hiring nurses.

實際上我們對第四季的這個數字非常滿意。如果你回顧去年，那是一個負淨值。如果您考慮一年中招募新員工極其困難的時期，那就是假期前後，尤其是第四季度。因此，我們的城鎮收購團隊在幫助支持醫院以及新的擴張以及尋找和僱用護士方面非常成功。

We've talked about in past calls, too, that we have a real focus on retention in our hospitals to retain the nurses that we already employ with a particular focus on those that have been hired in the last year or so. So we're very pleased with the progress that we've made and our hiring of RNs and would accept this year to be another strong year with that.

我們在過去的電話中也談過，我們真正關注的是保留我們醫院的護士，以留住我們已經僱用的護士，特別是去年左右僱用的護士。因此，我們對我們所取得的進展以及對註冊護士的聘用感到非常滿意，並認為今年將是另一個強勁的一年。

Yes. We can't necessarily assume the run rate that we saw in new hires in Q4 is going to stay steady across all 4 quarters in 2024 because there will be some seasonality to that. But as Mark said, we're very pleased there.

是的。我們不一定假設第四季度新員工的流動率會在 2024 年的所有 4 個季度保持穩定，因為這會存在一些季節性。但正如馬克所說，我們對此感到非常滿意。

With some specifics on turnover, our RN turnover for all of 2023 was down 500 basis points from 2022 and therapy, which has always been best of class and low from a turnover perspective was down 130 basis points on a year-over-year basis. So a combination of new hires and reducing turnover rate is really allowing us to manage those premium labor costs better.

根據營業額方面的一些具體情況，我們2023 年全年的註冊護士營業額比2022 年下降了500 個基點，而從營業額角度來看一直是同類最佳且較低的治療方法同比下降了130個基點。因此，新員工和降低流動率的結合確實使我們能夠更好地管理這些優質勞動力成本。

Now frankly, the 1.4% that we saw in terms of contract labor, FTEs as percentage of total FTEs in the fourth quarter was better than we had anticipated. We assumed that we'd get kind of a stabilization point around 1.5%. As we've noted previously, we had run just below 1% pre the Q3 of 2021 when the spike occurred for the overall industry. We'd like to see continued progress towards that number, but it's just very hard to predict.

坦白說，第四季合約工 FTE 佔 FTE 總數的百分比為 1.4%，好於我們的預期。我們假設我們會得到 1.5% 左右的穩定點。正如我們之前指出的，在 2021 年第三季之前，當整個產業出現高峰時，我們的成長率略低於 1%。我們希望看到這個數字繼續取得進展，但這很難預測。

Embedded in our guidance assumptions for 2024 is that from a total dollar perspective, premium labor cost in 2024 remain relatively consistent with the run rate that we established in Q4, which was down an aggregate of $2.7 million sequentially from Q3.

我們對2024 年的指導假設中包含的是，從總金額的角度來看，2024 年的優質勞動力成本與我們在第四季度確定的運行率保持相對一致，比第三季度總共下降了270 萬美元。

Our next question will come from Ben Hendricks with RBC Capital Markets.

我們的下一個問題將由加拿大皇家銀行資本市場部門的本·亨德里克斯（Ben Hendricks）提出。

This is Mike Murray on for Ben. So it sounds like internal SWB per FTE growth is expected to moderate in 2024 after a few years of acceleration. Just broadly, can you talk a little bit more about the labor market and what you're seeing for wage inflation? And do you think this will continue to moderate moving forward?

這是麥克·默里（Mike Murray）替補本。因此，聽起來，在經歷了幾年的加速之後，每 FTE 的內部 SWB 成長預計將在 2024 年放緩。概括地說，您能多談談勞動市場以及您對薪資通膨的看法嗎？您認為這種情況會繼續緩和嗎？

As I said, Mike, we've got -- the internal SWB per FTE assumption is an increase to 4% to 5%. And frankly, that's probably a point higher on both ends of the range than I was thinking about at the end of Q3.

正如我所說，麥克，我們假設每 FTE 的內部 SWB 增加到 4% 到 5%。坦白說，這個範圍的兩端可能都比我在第三季末考慮的要高一些。

What we are seeing is that although overall labor market conditions are improving, it's important to really stay on top of market adjustments. And as we're bringing in these larger number of new hires, if they're coming in at a market rate that is different than what we're paying the extant workforce, we've got to make sure that there's parity across that.

我們看到的是，儘管勞動市場整體狀況正在改善，但真正掌握市場調整的情況也很重要。當我們引進大量新員工時，如果他們的市場工資與我們向現有員工支付的工資不同，我們必須確保兩者之間的平等。

We -- again, across all of the metrics that we've cited, we're seeing improving labor market conditions. We're optimistic that, that will improve, particularly as we progress into the second half of 2024, but it's difficult to bank on that. So we went with a set of assumptions that I think reflect the current environment and no further improvement as we progress through the year.

再次，在我們引用的所有指標中，我們看到勞動力市場狀況正在改善。我們樂觀地認為，這種情況將會改善，特別是隨著我們進入 2024 年下半年，但很難指望這一點。因此，我們採用了一系列假設，我認為這些假設反映了當前的環境，並且隨著我們在這一年的進展，沒有進一步的改進。

Mike, we've tried to make sure that our hospitals have stayed at the market in terms of their rates with the market analysis that we have. Once you get behind market, it's awfully difficult to catch up, and it typically costs you more once you get behind than if you had stayed at the market level all along through market adjustments.

麥克，我們已盡力確保我們的醫院根據我們現有的市場分析，其費率符合市場水準。一旦落後於市場，就很難追趕，而且一旦落後，你所付出的代價通常比透過市場調整一直保持在市場水準要高。

If you look at between the market adjustments we've done in the last 1.5 years and the new staff that we brought on, there's a pretty high percentage of our overall staff that have had some adjustment or another. So that's part of the logic that we took going into the assumptions for this year.

如果你看看我們在過去 1.5 年所做的市場調整和我們引進的新員工，你會發現我們整體員工中有相當高的比例進行了一些調整或其他調整。這就是我們今年的假設所採用的邏輯的一部分。

And I think it's all proving to be a very good trade. I mean you tie together a bunch of these domestic or metrics, look at the volume growth. At no point during 2023 did we find ourselves constrained in being able to take volume and to take it safely and in the best interests of the patient because of labor constraints. Our turnover rates, as I've cited before, are down markedly for both RNs and therapists on a year-over-year basis, and our salaries are competitive enough that we're continuing to have great progress in recruiting new clinicians into our workforce.

我認為這一切都被證明是一筆非常好的交易。我的意思是，你將這些國內或指標結合起來，看看銷量的成長。在 2023 年期間，我們從未發現自己因勞動力限製而無法安全地獲取劑量並符合患者的最大利益。正如我之前提到的，我們的註冊護士和治療師的流動率逐年顯著下降，而且我們的薪水俱有足夠的競爭力，因此我們在招募新臨床醫生加入我們的員工隊伍方面繼續取得巨大進展。

One final note on labor. It should be noted that our talent acquisition team has helped us open up the vast majority of the de novos in the last couple of years with 0 contract labor at the time of opening. So it's been a huge support in terms of our ability to take the volume that Doug alluded to and to start off in these markets on the new markets on a good, solid fitting.

關於勞工的最後一點說明。值得注意的是，我們的人才引進團隊幫助我們在過去幾年以0合約工的方式開設了絕大多數新專案。因此，這對我們獲得道格提到的銷售以及在新市場上以良好、穩固的配合開始進入這些市場的能力而言是一個巨大的支持。

And the efficacy of the centralized talent recruiting function also comes with an efficiency. And to their credit, our HR team has been very creative in looking at the ways that we were expending dollars across the recruiting function to find out where those were having the greatest impact and then concentrating the dollars in those areas. So even with the success we had on new hires during the course of 2023, we actually did that with a year-over-year decrease in recruiting costs.

集中人才招募功能的功效也伴隨著效率。值得讚揚的是，我們的人力資源團隊非常有創意地研究了我們在招募職能中花費資金的方式，以找出影響最大的方面，然後將資金集中在這些領域。因此，儘管我們在 2023 年在新員工方面取得了成功，但實際上我們的招募成本卻逐年下降。

Okay. That's very helpful. Just shifting gears a little bit. I know you're working at moving more contracts towards case mix. I just wanted to see how this is progressing.

好的。這非常有幫助。只要稍微換一下檔位即可。我知道您正在努力將更多合約轉向案例混合。我只是想看看事情進展如何。

Yes. We continue to make great progress there. We have -- just about 90% of our MA contracts are on an episodic versus a per diem basis. And the rate differential, even as we continue to grow Medicare Advantage at a rate greater than our other payer categories as compared to fee-for-service remains less than 5%.

是的。我們在那裡繼續取得巨大進展。我們大約 90% 的 MA 合約是臨時的而不是每日的。即使我們繼續以高於其他付款人類別的速度成長 Medicare Advantage，與按服務收費相比，費率差異仍然低於 5%。

Our next question will come from Brian Tanquilut with Jefferies.

我們的下一個問題將來自 Jefferies 的 Brian Tanquilut。

This is Taji on for Brian. Congrats on the quarter. So unfortunately, just one more question about labor. Just currently, are you able to fill all the demand that you're seeing in the market? And if not, how much more labor would you need to see you upsize like that volume growth?

這是布萊恩的塔吉。恭喜本季。不幸的是，還有一個關於勞工的問題。目前，您能滿足市場上的所有需求嗎？如果沒有，您需要增加多少勞動力才能實現像銷售成長那樣的規模擴張？

Yes. As I just mentioned, at no point in 2023 were we are unable to take volume because of labor constraints. And we'll continue to prioritize -- we are going to serve all of the patients who are in need of inpatient rehabilitative care in the markets in which we are in, even if it means paying premium labor.

是的。正如我剛才提到的，2023 年我們在任何時候都不會因為勞動力限製而無法擴大產量。我們將繼續優先考慮——我們將為我們所在市場中所有需要住院復健護理的患者提供服務，即使這意味著支付高額勞動力。

Okay. And then this is a slight follow-up from Joanna's question. I know you had called out differences you're seeing in different condition categories. Just wanted to follow up and see if there are any specialties where you see that -- see it as an incremental opportunity in terms of volume growth or revenue yield. I know you called out increasing investment and like expansion of your in-house dialysis, but I wanted to see if there's anything else you're thinking about.

好的。這是喬安娜問題的一個小小的後續。我知道您已經指出了在不同條件類別中看到的差異。只是想跟進一下，看看是否有任何專業領域可以看到這一點——將其視為銷售成長或收入收益的增量機會。我知道您呼籲增加投資並希望擴大內部透析，但我想看看您是否還有其他考慮。

So we've put a big focus on the neurological categories as a whole for the past several years. We call out stroke because we think we have a particular -- strong outcomes. We feel like there's a huge demand for stroke rehabilitation. We think we do a really good job in getting these patients back to the community. And we've partnered with the American Stroke Association nationally to help promote the need and education for stroke patients.

因此，過去幾年我們將重點放在整個神經學類別。我們稱中風是因為我們認為我們有一個特別的——強有力的結果。我們認為中風復健的需求龐大。我們認為我們在讓這些患者重返社區方面做得非常好。我們與美國中風協會在全國範圍內合作，幫助促進中風患者的需求和教育。

So we call at stroke specifically. As Doug noted, we had almost a 5% growth in that last year, and it remains one of our top categories in terms of percentage of total discharges. So between stroke and other neurological, I would call those out as areas that we see continued opportunities to grow.

所以我們特意稱之為中風。正如 Doug 指出的那樣，去年我們的排放量增加了近 5%，並且就佔總排放量的百分比而言，它仍然是我們的首要類別之一。因此，在中風和其他神經系統疾病之間，我認為這些領域是我們認為有持續成長機會的領域。

I think the other one that I would point to and perhaps one that we don't count enough and maybe don't get enough credit for in a forum like this is dealing with brain injury patients. And so brain injury typically runs between 10% and 12% of our overall patient mix, and it was up 10.5% in the quarter. Obviously, that's a very medically-complex patient, and so they can't be treated effectively in too many settings.

我想我要指出的另一個問題是處理腦損傷患者，也許我們在這樣的論壇中沒有得到足夠的重視，也可能沒有得到足夠的認可。因此，腦損傷通常占我們患者總數的 10% 到 12%，本季增加了 10.5%。顯然，這是一位醫療狀況非常複雜的患者，因此在太多環境下無法對他們進行有效治療。

(Operator Instructions) We'll now hear from Jared Haase with William Blair.

（操作員說明）我們現在將聽取 Jared Haase 和 William Blair 的發言。

Appreciate all the detailed commentary thus far. Maybe I'll just take a step back and ask a bigger picture question. I'm curious to hear your perspective just around the outlook for Medicare Advantage environment in general. Obviously, there's been a lot of focus lately just around rates for the plans and the broader utilization that those guys are experiencing. I would just love to get your perspective on the group in a general sense and then how you're sort of thinking about maybe potential leverage in terms of rate negotiations or just your general value proposition in partnering with MA plans?

感謝迄今為止所有詳細的評論。也許我會退後一步，問一個更大的問題。我很想聽聽您對 Medicare Advantage 環境整體前景的看法。顯然，最近人們對這些計劃的費率和這些人正在經歷的更廣泛的利用產生了許多關注。我只是想從一般意義上了解您對該集團的看法，然後您如何考慮利率談判方面的潛在影響力，或者只是您與 MA 計劃合作的總體價值主張？

Yes. So again, we think there continues to be significant upside in Medicare Advantage for us. Although the growth rate over the last several years has been very impressive. If you look again at the 4-year CAGR, same-store CAGR for Medicare Advantage extending from 2019, and I picked 2019 specifically to go back before COVID and run that through 2023, our Medicare Advantage same-store is up 15.2%. So it's our fastest-growing category.

是的。因此，我們再次認為醫療保險優勢對我們來說仍然有顯著的上升空間。儘管過去幾年的成長速度非常驚人。如果你再看一下自2019 年以來Medicare Advantage 的4 年複合年增長率（CAGR），即同店複合年增長率（CAGR），我特意選擇了2019 年作為新冠疫情之前的年份，並一直持續到2023年，我們的Medicare Advantage 同店複合成長率成長了15.2%。所以這是我們成長最快的類別。

But we've been able to grow that while maintaining or increasing the number of those contracts that are paid on a case rate basis versus a per diem and keeping that narrowing and then keeping that payment differential versus fee-for-service at less than 5%. I think the real opportunity is that we continue to see conversion rates in Medicare Advantage, and that means the number of admits as a percentage of referrals that is lower, significantly lower than Medicare fee for service.

但我們已經能夠在保持或增加按案件費率與每日津貼支付的合約數量的同時，保持這種收入的增長，並保持縮小範圍，然後將支付與服務費用的差異保持在 5 以下。 %。我認為真正的機會是我們繼續看到 Medicare Advantage 的轉換率，這意味著入院人數佔轉介的百分比較低，明顯低於 Medicare 服務費用。

And some of the pressures or some of the focus that you're now seeing from CMS on the MA plan is about denial of access to care and utilizing internal metrics and algorithms to authorize care for Medicare Advantage patients, which is not necessarily directing those patients to the place where they can expect the best outcome. We think that those trends will bode well for us in the future just based on the quality of outcomes that we're producing and the complexity of the patients that we're able to treat effectively.

您現在從 CMS 看到的關於 MA 計劃的一些壓力或一些焦點是關於拒絕獲得護理以及利用內部指標和算法授權對 Medicare Advantage 患者進行護理，這不一定是指導這些患者到他們可以期待最好結果的地方。我們認為，基於我們正在產生的結果的品質以及我們能夠有效治療的患者的複雜性，這些趨勢對我們來說是一個好兆頭。

Got it. That makes a lot of sense. And then maybe I'll just ask a quick follow-up. Thinking about specifically any priorities you guys would call out in 2024 just around technology investments or other workflow improvements. I think you alluded to some of the things around predictive analytics and obviously, you have the dialysis technology that you're rolling out as well. But just really curious to hear if anything new or incremental on the road map this year that's focused kind of on driving clinical or operational improvement.

知道了。這很有意義。然後也許我會要求快速跟進。具體考慮一下你們在 2024 年提出的圍繞技術投資或其他工作流程改進的優先事項。我認為您提到了有關預測分析的一些內容，顯然，您也擁有正在推出的透析技術。但我真的很想知道今年的路線圖上是否有任何新的或增量的內容，重點是推動臨床或營運改善。

You've named a couple of them. We always look at innovations that are out there, whether that is through the utilization and of this huge amount of data that we've been able to collect from our clinical information system over the years and working with our clinical team on predictive analytics and driving our clinical outcomes.

你已經說出了其中幾個的名字。我們始終專注於現有的創新，無論是透過利用多年來我們從臨床資訊系統收集的大量數據，還是與我們的臨床團隊合作進行預測分析和驅動我們的臨床結果。

We look at the new technologies that are out there, particularly on the clinical aspects, either for nursing or therapies that will help us assist in treating our patients. There are a number of them that were working in full this year around dysphagia, helping the patients in their swallowing difficulties, which is a common issue with stroke patients. We have weight-assisted devices in our gyms that can help our patients in ambulation around.

我們專注於現有的新技術，特別是在臨床方面，無論是護理還是治療，都將幫助我們協助治療患者。今年，他們中的許多人圍繞著吞嚥困難全力以赴，幫助患者解決吞嚥困難，這是中風患者的常見問題。我們的健身房裡有重量輔助設備，可以幫助我們的患者四處走動。

So there, on any given year, including 2024, we take access to innovation in a number of different studies, particularly if it enables our staff to get better outcomes or helps them become more efficient.

因此，在任何一年，包括 2024 年，我們都會在許多不同的研究中獲得創新，特別是如果它能讓我們的員工獲得更好的結果或幫助他們提高效率。

We believe our competitive advantage in this regard is self-perpetuating providing that we operate under a philosophy of continuous improvement. And by that, I mean, if you look at the common conditions that are treated in the IRF setting, just based on our scale and our market share, we see far more of those patients than any of our competitors by a very wide margin. And we utilize the data that comes from seeing that vast number of patients to get smarter about the clinical protocols and the outcomes that they produce.

我們相信，只要我們在持續改善的理念下運營，我們在這方面的競爭優勢就會自我延續。我的意思是，如果你看看 IRF 環境中治療的常見病症，僅根據我們的規模和市場份額，我們看到的此類患者比我們的任何競爭對手都要多得多。我們利用透過觀察大量患者所獲得的數據來更明智地了解臨床方案及其產生的結果。

And our clinical leaders have been really, really focused. They never rest on their laurels and they're focused on just continuously getting better at what we do, analyzing the data that comes through on almost every patient saying, how do we refine our models, how do we refine the protocols that we're using to become even more effective in treating these patients.

我們的臨床領導者非常非常專注。他們從不滿足於自己的成就，他們專注於不斷改進我們所做的事情，分析幾乎每個患者的數據，他們說，我們如何完善我們的模型，我們如何完善我們正在製定的方案以便更有效地治療這些患者。

Our next question will come from Scott Fidel with Stephens.

我們的下一個問題將由斯科特·菲德爾和史蒂芬斯提出。

We'd say Scott, but we don't want to be presumptive.

我們會說斯科特，但我們不想假設。

It's actually Scott here for -- the real Scott...

實際上斯科特來這裡是為了——真正的斯科特…

Which is not in any way to express disappointment regarding any of the others.

這並不是以任何方式表達對其他任何人的失望。

Understood, understood. I want to ask you just about balance sheet capacity here, just given how you did end up with leverage down below the long-term target range. Obviously, a high interest rate environment, so that's not necessarily a terrible thing. But it does seem like you still have a lot of capacity incrementally here. And just how you're thinking about that for 2024 and whether that would influence thinking about potentially ramping up capital returns such as the buyback more or further accelerating some of your growth investments? Or are you just comfortable keeping leverage below target here just given the cost of capital environment?

明白了，明白了。我想問您有關資產負債表容量的問題，只是考慮到您最終如何將槓桿率降至長期目標範圍以下。顯然，在高利率環境下，這不一定是一件可怕的事。但看起來你這裡仍然有很多增量容量。您如何看待 2024 年的情況？這是否會影響對潛在提高資本回報的考慮，例如更多回購或進一步加速您的一些成長投資？或者考慮到資本環境成本，您是否願意將槓桿率保持在目標以下？

Yes. So Scott, if you go back to 2022, we were running just about $600 million in total CapEx, and we were essentially at breakeven from a cash flow perspective. As a matter of fact, I think we -- beyond funding almost all of that plus the dividend with internally generated funds, I think our debt increased modestly, maybe $25 million or $50 million.

是的。 Scott，如果你回到 2022 年，我們的資本支出總額約為 6 億美元，從現金流的角度來看，我們基本上處於損益平衡狀態。事實上，我認為我們——除了用內部產生的資金資助幾乎所有這些資金加上股息外，我認為我們的債務略有增加，可能是 2500 萬美元或 5000 萬美元。

As we came into 2023, with a CapEx budget that was in aggregate, pretty similar and with an assumption that the dividend would be relatively constant, based on our initial guidance, we were assuming that we would once again be essentially breakeven in 2023. And we didn't necessarily at that time, think that it would be prudent given that we were starting the year with a 3.4x net leverage to start deploying capital towards other potential utilizations like further shareholder distributions.

當我們進入 2023 年時，根據我們最初的指導，資本支出預算總體上非常相似，並且假設股息相對恆定，我們假設我們將在 2023 年再次基本上實現盈虧平衡。考慮到我們以3.4 倍的淨槓桿率開始將資本部署到其他潛在用途（例如進一步的股東分配），我們當時不一定認為這是謹慎的做法。

Well, through the course of 2023, we underspent a bit mostly based on timing with regard to CapEx. And we overperformed with regard to EBITDA and adjusted cash flow. So that number brought the leverage down, but it created more capacity for us earlier than we had anticipated to start really thinking about some of these additional uses of capital allocation. And shareholder distributions is the one that comes immediately to mind once we get beyond funding our discretionary CapEx.

嗯，在 2023 年期間，我們的支出有所不足，主要是因為資本支出的時間安排。我們在 EBITDA 和調整後現金流方面表現出色。因此，這個數字降低了槓桿率，但它為我們創造了更多的能力，比我們預期的更早開始真正考慮資本配置的一些額外用途。一旦我們超出了為可自由支配的資本支出提供資金的範圍，我們立即想到的就是股東分配。

So it is certainly something that the Board is going to be considering through the course of this year. We frankly got in a position to be able to have that consideration sooner than we had anticipated.

因此，這肯定是董事會今年要考慮的事情。坦白說，我們能夠比我們預期的更早考慮到這一點。

Okay. Great. So we'll certainly keep an eye out for that. And then just a follow-up question just around modeling for seasonality. Anything you'd want to call out just from either EBITDA or cash flow from the sort of the quarterly modeling progression that's -- that would be different than normal patterns? Or should we think about it sort of consistent with typical patterns?

好的。偉大的。所以我們一定會密切關注這一點。然後是關於季節性建模的後續問題。您想從 EBITDA 或季度建模進展中的現金流量中得出任何與正常模式不同的東西嗎？或者我們應該認為它與典型模式一致？

It really feels like after a period of some normalization being required that we've kind of gotten back into our regular seasonal pattern in terms of volume flows. And so the biggest difference year-over-year is going to be the timing and the impact of the de novos.

確實感覺到經過一段時間的正常化之後，我們在流量方面已經回到了正常的季節性模式。因此，與去年同期相比，最大的差異將在於重新啟動的時間和影響。

Our next question will come from Parker Snure with Raymond James.

我們的下一個問題將由帕克·斯努爾和雷蒙德·詹姆斯提出。

This is Parker on for John Ransom. I just want to shift over to the 2024 guidance. So if I look at the guidance or if I just look at your fourth quarter 2023 EBITDA, you did $255 million of EBITDA. If I normalize that for the bad debt charge, that's $271 million. If you annualize that, you get $1.80 billion maybe there's some added de novo costs in there, so maybe let's say, $1.65 billion is kind of the run rate. But your guidance is $1.35 billion.

這是帕克為約翰·蘭塞姆發言。我只想轉向 2024 年指引。因此，如果我查看指導，或僅查看您 2023 年第四季度的 EBITDA，您的 EBITDA 為 2.55 億美元。如果我將壞帳費用標準化，那就是 2.71 億美元。如果你按年計算，你會得到 18 億美元，也許其中還有一些額外的從頭成本，所以也許可以說，16.5 億美元是運行率。但你的指導是 13.5 億美元。

So maybe just talk about why would there be a difference there? Is there a reason -- were there certain items in the fourth quarter that were kind of more onetime in nature? And why wouldn't the fourth quarter run rate be a good kind of jumping off point as we look into 2024?

那麼也許只是談談為什麼會有差異？有沒有什麼原因——第四季的某些項目本質上是一次性的？當我們展望 2024 年時，為什麼第四季的運作率不是一個很好的起點呢？

Yes. So first, you back out of that $9 million in workers' comp and GPO prior period reserve adjustments, then you normalize for a favorable group medical expense. Then as you suggested, the de novos for 2023 contributed $1 million in EBITDA in Q4, the assumption for all of 2024 and is that you're going to have $15 million to $18 million, some portion of that attributable to Q4. So you've got a swing there.

是的。因此，首先，您取消 900 萬美元的工人補償和 GPO 前期準備金調整，然後您將獲得有利的團體醫療費用正常化。然後，正如您所建議的，2023 年的de novos 在第四季度貢獻了100 萬美元的EBITDA，這是對2024 年全年的假設，您將獲得1500 萬至1800 萬美元，其中一部分歸因於第四季。所以你在那裡有一個鞦韆。

And then again, our core assumption is that you've got 4% to 5% labor inflation, which is going to delever to some extent against the pricing. On top of that, you've got more nuanced items. We continue to believe that EPOB will normalize towards 3.48. We're pretty close there right now at 3.38 for fiscal year 2023 in aggregate. That's a highly sensitive ratio. So even if you just moved up from 3.38 to 3.4 which 2/100 of an impact, that's about a $14 million to $15 million impact on year-over-year EBITDA.

再說一次，我們的核心假設是勞動通膨率為 4% 到 5%，這將在一定程度上降低定價的槓桿率。最重要的是，你還有更多細緻的項目。我們仍然相信 EPOB 將正常化至 3.48。目前我們非常接近 2023 財年的 3.38 水準。這是一個高度敏感的比率。因此，即使您只是從 3.38 提高到 3.4，即 2/100 的影響，這對同比 EBITDA 的影響約為 1,400 萬至 1,500 萬美元。

So it's -- I think it's a combination of all those things. And we're here, we're a month into 2024. And so what we have demonstrated consistently is, particularly with regard to guidance is we call balls and strikes very consistently. So the guidance that we're providing right now is according to the philosophy that we have consistently applied that if the business is out there and if the environment is better, we'll deliver better results. But we think that this is a reasonable set of assumptions starting the year.

所以我認為這是所有這些事情的結合。距離 2024 年還有一個月了。我們一貫所展示的是，特別是在指導方面，我們對球和擊球的稱呼非常一致。因此，我們現在提供的指導是根據我們一貫應用的理念，即如果業務存在並且環境更好，我們將提供更好的結果。但我們認為這是從今年開始的一組合理假設。

Okay. Yes. That's fair. And if I can just squeeze in one more, just related to the bad debt charge. I know you guys said you changed some of your reserving practices as you move into next year. Is there any chance that there could be another one of these kind of one-off reserve charges? Or is it kind of the expectation that this was a one-off and that shouldn't recur?

好的。是的。這還算公平。如果我能再擠進去一份，就跟壞帳費用有關。我知道你們說過，進入明年後，你們改變了一些預訂做法。是否有可能再次收取此類一次性準備金費用？或者這是一種預期，認為這是一次性的並且不應該再次發生？

It's really the latter. We didn't necessarily change our reserve methodology right? Because the reserve methodology that's in place right now is really looking specifically at TPE, which had been suspended for a while and came back on, but the activity there is a lot lower than it ever was under the widespread probes that stopped in 2018.

確實是後者。我們不一定要改變我們的儲備方法，對吧？因為現在採用的儲備方法實際上是專門針對 TPE 的，該貨幣已暫停了一段時間並重新啟動，但那裡的活動比 2018 年停止的廣泛調查下的活動要低得多。

The write-off that we took this quarter, the $16 million EBITDA impact related to those older claims that originated, 97% of them were prior to 2018. And it related specifically to the fact that when we started appealing these things up to the DAB level -- I mean to the Federal District Courts, we didn't have any experience on which to base a specific reserve methodology.

我們本季進行的沖銷，1600 萬美元的 EBITDA 影響與那些較早的索賠相關，其中 97% 是在 2018 年之前。這與我們開始向 DAB 上訴這些事情的事實有關。我的意思是，對於聯邦地方法院來說，我們沒有任何經驗可以作為具體準備金方法的基礎。

We're a year into it right now. And unfortunately, what we found is that the claims denials that were essentially rubber stamped as the ALJ ramped up, its number of judges in an attempt to clear the backlog is dictated by the federal court ruling that they were getting rubber stamped at the higher levels as well.

我們現在已經一年了。不幸的是，我們發現，隨著行政法官的力度加大，否認索賠基本上是橡皮圖章，其試圖清理積壓案件的法官人數是由聯邦法院的裁決決定的，他們在更高級別上得到了橡皮圖章以及。

So it's frustrating. We look back at that backlog of claims, which has now been largely resolved. The balance is still out there on our balance sheet, it's essentially fully reserved. We look back at those claims and say we did the right things, we admitted the right patients and we treated them effectively and yet we're going to take these write-offs and move on.

所以這很令人沮喪。我們回顧一下積壓的索賠案件，目前該問題已基本解決。餘額仍然存在於我們的資產負債表上，它基本上是完全保留的。我們回顧這些說法，並說我們做了正確的事情，我們收治了正確的患者，我們有效地治療了他們，但我們將沖銷這些費用並繼續前進。

We have a follow-up question from Kevin Fischbeck with Bank of America.

我們有美國銀行凱文·菲施貝克 (Kevin Fischbeck) 提出的後續問題。

This is Joanna. So I guess a little bit a different topic, but I guess the proposed regulation cycle also creeping up on us. So kind of your expectations for 2025 proposed rule, what you expect there when it comes to rate update or anything else? And I guess, specifically, the home health transfer policy change that I guess was lagged prior to '24 cycles.

這是喬安娜。所以我想這是一個有點不同的話題，但我想擬議的監管週期也在悄悄發生在我們身上。您對 2025 年擬議規則的期望是什麼？在費率更新或其他方面您有何期望？我想，具體來說，家庭健康轉移政策的變化我認為是滯後於「24 週期」之前的。

So do we expect this to show up in '25? Or would you expect this to kind of die down? Because I guess when you think about it, if you would be here, like why should this -- seem as -- just do this because I guess the hospitals have the same transit policy? So why would that be different? But any thoughts in terms of expectations for that?

那麼我們預計這會在 25 年出現嗎？或者你希望這種情況會逐漸平息嗎？因為我想當你想到這一點時，如果你會在這裡，就像為什麼要這樣做——似乎——只是這樣做，因為我猜醫院有相同的交通政策？那為什麼會有所不同呢？但對此有什麼期望嗎？

Joanna, this is Mark. Let me take the latter point. We've not heard any feedback relative to the home health transfer ruling more from CMS other than what was discussed last year as they did the RFI. I think, at that time, the industry made a pretty good case why the home health transfer rule is a little bit different when you think about IRFs, and the primary point being that home health or an IRF patient is not a substitution of care. And it's actually a normal progression of care for a rehabilitation patient.

喬安娜，這是馬克。讓我來談談後一點。除了去年在 RFI 中討論的內容之外，我們還沒有從 CMS 聽到任何有關家庭健康轉移裁決的任何反饋。我認為，當時業界提出了一個很好的案例，為什麼當你考慮 IRF 時，家庭健康轉移規則有點不同，主要的一點是家庭健康或 IRF 患者不能取代照護。這其實是復健患者的正常照護過程。

And I think it was also pointed out that the average length of stay for IRF patients across CMGs has been remarkably consistent. In other words, they've not seen it from a perspective that there was a financial mode to reduce average length of stay. And those are all different aspects than if you've looked at other sectors in healthcare where there have been a transfer rule.

我認為有人也指出，各個 CMG 的 IRF 患者的平均住院時間非常一致。換句話說，他們並沒有從一個角度看到有一種金融模式可以減少平均停留時間。這些都是與您查看醫療保健領域其他有轉移規則的部門不同的方面。

So we've not heard anything. If there is information or an act included within the proposed rule or make it through the final rule. We'll do what we've done with all the other regulatory changes in our history. We'll evaluate it. We'll digest the new rule. We'll understand it. And we believe we'll adjust accordingly, just like we've done historically with other major changes.

所以我們什麼也沒聽到。如果提議的規則中包含資訊或行為或使其通過最終規則。我們將像我們歷史上所有其他監管變革所做的那樣。我們會評估它。我們將消化新規則。我們會理解的。我們相信我們會做出相應的調整，就像我們歷史上對其他重大變化所做的那樣。

Yes. Not to beat our chest, but I don't know that you can point to another provider that over its history has demonstrated greater adeptness and agility at responding to regulatory changes.

是的。不是為了拍我們的胸脯，但我不知道您是否可以指出另一家供應商，該提供者在其歷史上在應對監管變化方面表現出了更大的技巧和敏捷性。

And underlying all of this is the fact that the demand for inpatient rehabilitative services in this country is currently underserved and is only going to continue to grow based on the underlying demographic. Those patients need to be treated by somebody, and we are the most effective at treating those patients in either of those services and expanding the capacity to do that. So regardless of what comes down the pipe from a regulatory perspective, we will adjust to it with alacrity and we will continue to grow our business.

所有這一切的根本原因是，該國對住院復健服務的需求目前服務不足，並且根據基本人口統計只會繼續增長。這些患者需要有人治療，而我們在這些服務中治療這些患者並擴大治療能力方面是最有效的。因此，無論從監管角度來看會發生什麼，我們都會迅速適應，並繼續發展我們的業務。

Our final question will come from A.J. Rice with UBS.

我們的最後一個問題將來自 A.J.賴斯與瑞銀。

A couple of quick things here. I know you were saying in the deck that you're looking for a 2% to 3% increase in your managed care and that's a small piece of the overall business. But I was curious if any updated commentary or discussions about value-based arrangement, incentive type of programs, any discussion along those lines?

這裡有幾件事。我知道您在演講中說過，您希望管理式醫療服務成長 2% 到 3%，但這只是整個業務的一小部分。但我很好奇是否有任何關於基於價值的安排、激勵類型的計劃的最新評論或討論，是否有任何類似的討論？

A.J., it's -- I know it's going to sound redundant with what we said previously. We really just don't see much of that dialogue with the MA plan. A, it's complex. And I think in terms of their overall book of business, we're still relatively small. So the emphasis -- now if we get any inquiries from an MA plan about our willingness and our ability to participate in those types of models, we are -- we expressed a great desire to do so.

A.J.，我知道這聽起來與我們之前所說的有些多餘。我們確實沒有看到與 MA 計劃進行太多對話。答：很複雜。我認為就他們的整體業務而言，我們仍然相對較小。因此，重點是——現在，如果我們從 MA 計劃中得到任何關於我們參與這些類型模型的意願和能力的詢問，我們就會——我們表達了這樣做的強烈願望。

Most of the discussions are really centering on the efficacy of our outcomes, the overall value proposition and the benefits to all parties involved in moving to a case rate structure where we're able to manage the MA patients to what we believe is the greatest clinical efficiency.

大多數討論實際上都集中在我們結果的有效性、總體價值主張以及涉及病例發生率結構的所有各方的利益，在這種結構中，我們能夠以我們認為最好的臨床水平來管理 MA 患者效率。

Okay. And then I know you said your affirmation rates on the demonstration project is hitting above the 80%, which is the target. I think that was supposed to be a 6-month project, if I have it right. Any sense of where we go from here, if everyone -- the major players are hitting the targets? Does it just get dropped? Do you think they're going to make a change on any of this? Do we have any idea?

好的。然後我知道你說你對示範計畫的肯定率達到了​​80%以上，這是目標。如果我沒記錯的話，我認為這應該是一個為期 6 個月的專案。如果每個人——主要參與者都達到了目標，我們接下來會走向何方？它會被丟棄嗎？你認為他們會對此做出改變嗎？我們有什麼想法嗎？

A.J., it's Mark. As it's laid out now, I mean, the initial 6 months will end at the end of February. And so it's projected to go from 80% to 85% and then ultimately up to 90%. So we would expect it to go up to 85%. I think, certainly, given the affirmation rate that the industry has seen and CMS is seeing, it's -- we'll see where that goes from here.

A.J.，是馬克。我的意思是，按照現在的安排，最初的 6 個月將在 2 月底結束。因此預計將從 80% 增加到 85%，最終達到 90%。所以我們預計它會上升到 85%。我認為，當然，考慮到行業和 CMS 所看到的肯定率，我們將看看接下來會發生什麼。

As its noted, the 5-year demonstration, so if they take the entire 5 years, we're not sure. But as you note, if the entire industry is performing quite well, you'd wonder why they would continue on with it.

正如其所指出的，這是為期 5 年的演示，所以如果他們花了整整 5 年的時間，我們不確定。但正如您所指出的，如果整個行業表現良好，您會想知道為什麼他們會繼續這樣做。

They had identified some of the states that they wanted to go to next following the initiation in Alabama, Pennsylvania, Texas and then I think Florida, where on that list, not surprising given the number of IRFs in those states. It's our understanding that they have given -- CMS has given notice to the MAC, Novitas about ultimately starting up this project without a date certain this demonstration, excuse me, in Pennsylvania. We have 9 hospitals in Pennsylvania but all of our 9 hospitals are with a different MAC. That is Palmetto. And so as it stands right now, our hospitals in Pennsylvania would not be subject to the extension of that demonstration into Pennsylvania.

繼阿拉巴馬州、賓夕法尼亞州、德克薩斯州和佛羅裡達州啟動之後，他們已經確定了下一步想去的州，考慮到這些州的 IRF 數量，我認為名單上的佛羅裡達州並不奇怪。據我們了解，他們已經向 MAC 和 Novitas 發出了關於最終啟動該項目的通知，但沒有確定這次演示的具體日期，請原諒，在賓夕法尼亞州進行。我們在賓州有 9 家醫院，但所有 9 家醫院都有不同的 MAC。那就是棕櫚樹。因此，就目前情況而言，我們賓州的醫院不會受到將示威活動擴展到賓州的影響。

That will conclude the question-and-answer session. I will now turn the call over to Mark Miller for any additional or closing remarks.

問答環節就此結束。我現在將把電話轉給馬克·米勒，請他發表補充或結束語。

Thank you, operator. If anyone has additional questions, please call me at (205) 970-5860. Thank you again for joining today's call.

謝謝你，接線生。如果有人還有其他疑問，請致電 (205) 970-5860 與我聯絡。再次感謝您參加今天的電話會議。

This does conclude today's program. Thank you for your participation. You may now disconnect.

今天的節目到此結束。感謝您的參與。您現在可以斷開連線。