美國醫院公司 (HCA) 2014 Q4 法說會逐字稿

Welcome to the HCA fourth quarter 2014 earnings conference call.

Today's call is being recorded.

At this time, for opening remarks and introductions, I would like to turn the call over to Mr. Vic Campbell, Senior Vice President, Please go ahead, sir.

Chenille, thank you, and good morning, everyone.

Mark Kimbrough, our Chief Investor Relations Officer and I would like to welcome everyone here today on the call, as well as those of you who are listening to the webcast.

With me here this morning are Chairman and CEO, Milton Johnson; Sam Hazen, our Chief Operating Officer; and Bill Rutherford, our CFO.

Before I turn the call over to Milton, let me remind everyone that should today's call contain any forward-looking statements, they are based on management's current expectations.

Numerous risks, uncertainties and other factors may cause actual results to differ materially from those that might be expressed today.

Many of these factors are listed in today's press release and in our various SEC filings.

Several of the factors that will determine the company's future results are beyond the ability of the company to control or predict.

In light of the significant uncertainties inherent in any forward-looking statements, you should not place undue reliance on these statements.

The company undertakes no obligation to revise or update any forward-looking statements, whether as a result of new information or future events.

On this morning's call we may reference measures such as adjusted EBITDA and net income of attributable to HCA Holdings, Inc.

excluding losses or gains on sales of facilities, losses on retirement of debt and legal claims costs, which are non-GAAP financial measures.

A table providing supplemental information on adjusted EBITDA and reconciling to net income attributable to HCA Holdings, Inc.

to adjusted EBITDA is included in the company's fourth quarter earnings release.

As you heard, the call is being recorded and a replay will be made available later today.

And with that, I'll turn the call over to Milton.

All right.

Thank you, Vic, and good morning to everyone for joining us on the call or on the webcast.

I hope each of you has had the chance to review the release issued this morning, which is fairly consistent with the company's preview for the fourth quarter issued on January 9. I'll discuss the year and few other items, and turn the call over to Bill and Sam to provide additional details on the quarter, health reform and 2015 guidance.

We are extremely pleased with our results for the fourth quarter and for the full year 2014.

The fourth quarter performance was highlighted by strong volume metrics, favorable payer mix and excellent cost management.

As a result, we produced revenue growth of 9.1%, adjusted EBITDA growth of 14.1% and diluted EPS growth of 29.3% over the prior year's fourth quarter.

Earnings per diluted share, excluding the gains and losses on sales of facilities and losses on retirement of debt, increased 44.6% over the prior year's fourth quarter.

For the full year 2014, revenues totaled $36.9 billion compared to $34.2 billion last year, an increase of 8% compared to $6.574 billion in 2013.

Diluted earnings per share increased to $4.16 compared to $3.37 per share last year, an increase of 23.4%.

EPS per diluted share, excluding gains and losses on sales of facilities, losses on retirement of debt and legal claims cost, increased to $4.70 compared to $3.41 per share last year, an increase of 37.8%.

Our results clearly exceeded our internal expectations for 2014.

One of our key strength is our ability to create shareholder value through capital deployment.

For the full year 2014, we generated $4.45 billion of cash flows from operating activities, up 20.9% over 2013.

We reported approximately $2.2 billion in capital spending in our existing markets in 2014, and we acquired three hospitals and a number of non-hospital healthcare related entities for approximately $770 million.

These investments revolve in their access points and enhance our service capabilities in our markets.

Additionally, we repurchased 28.6 million shares of our stock for $1.75 billion in 2014, and today we announce the authorization of a new 1 billion share repurchase program.

With respect to our commitment to quality of care and patient safety, during the fourth quarter 85% of the company hospitals reporting core measure performance data were recognized as top performance by The Joint Commission.

Recognizing that we will increasingly be measured and reimbursed based on the quality and value of our services, improvement in patient outcome and patient service will be our top priority in 2015.

As a part of this emphasis, we recently hired our first Chief Patient Experience Officer, who will be responsible for servicing best practices that have been developed across 88 hospitals, as well as other healthcare providers to ensure our patients have the best hospital experience.

Our efforts to improve quality and service are not only important to our patients, but also to all of our caregivers and the employees that want to align the top quality organizations and pay our employers for receiving greater value.

We believe our operating strategies are highly effective and resource appropriately for 2015.

In addition to our robust clinical agenda, we will continue to develop local market networks for convenience and access, quality and deep service capabilities and position alignment.

A great example of improving convenience and access is our recently announced acquisition of CareNow, which operates 24 urgent care centers in the Dallas-Fort Worth market, with approximately 850,000 patient visits per year.

Now, moving to health reform.

We are pleased with our 2014 growth from healthcare reform, which largely resulted from our approach to exchange contracting.

For 2015, we remain disciplined with our pricing strategy and we have broadened our network participation in many of our large markets.

For example, we have increased our health exchange contracts by 37% over 2014.

Bill will provide additional information on health reform in just a few minutes.

And in closing, I must congratulate Sam Hazen on his appointment to HCA's Chief Operating Officer.

As many of you know, Sam has served in a number of executive roles during his 32-year career at HCA, most recently as President of Operations.

I have worked closely with Sam for many years, and I appreciate his commitment to achieving ever-improving operational performance that supports the best clinical outcomes for our patients.

As HCA continues to evolve its strategies in areas of clinical quality and physician engagement, a number of roles in the company have increased in significance and responsibilities.

As a result, we have promoted four HCA executives to HCA's senior management team.

These promotions not only are well-deserved, but I believe they enhanced our ability to achieve ever-increasing higher clinical performance and meet the many objectives we have, as an industry-leading organization.

And finally, we are excited by the inclusion of HCA in S&P 500 indices, starting from January 26.

We are happy to be part of this group.

With that, I'll turn the call over to Bill.

Okay, great.

Hey, thank you, Milton, and good morning, everybody.

I will cover some additional information relating the fourth quarter results, then I'll turn the call over to Sam for an update on operations, then I'll come back and discuss health reform detail and finish with the discussions surrounding our 2015 earnings guidance.

Once again, we were extremely pleased with the quarter's results.

Fourth quarter volume trends were some of the best we've experienced in a number of years.

This coupled with good payer mix and service mix and excellent expense management, combined to drive the quarter's and the year's strong performance.

For the quarter adjusted EBITDA, as reported, increased 14.1% to $1.956 billion from $1.714 billion last year.

We reported an improvement of 90 basis points in adjusted EBITDA margin in the quarter to 20.3%.

During the fourth quarter we recorded a $68 million increase in Medicaid revenues related to the Texas Medicaid Waiver Program, a reverse reduction made in the third quarter.

As a reminder, we made an adjustment in third quarter to reduce Medicaid revenues due to some uncertainty caused by the CMS inquiry of the Texas Medicaid Program and the payment deferral that was issued.

During the fourth quarter the company received approximately $161 million related to our outstanding receivables in CMS looking the deferral they had previously issued.

So these events gave us really the long assurance regarding recognized Medicaid revenues associated with the Texas Medicaid fiscal year ending September 30, 2014.

And thus, the $68 million adjustment was made in the fourth quarter.

However, we understand, CMS continues to inquire in certain aspects of the program on a go-forward basis.

As a result, the company reduced its Medicaid revenues by approximately $35 million in the fourth quarter and we expect to reduce Medicaid revenues by approximately $70 million in 2015, well prepared to what we recognized during the course of 2014.

We will continue to monitor developments relating to this program and update you on any material changes.

Adjusting for the impacts of these items as well as EHR income and share-based compensation, adjusted EBITDA grew 14.4% over the prior year for the quarter.

In the fourth quarter, our same facility admissions increased 5% over the prior year and equivalent admissions increased 5.6%.

Sam will provide more color on the composition of this volume in a moment.

During the fourth quarter, same facility Medicare admissions and equivalent admissions increased 6.1% and 5.8%, respectively.

This includes both traditional and managed Medicare.

Managed Medicare admissions increased 11.7% on same facility basis and represent 31% of our total Medicare admissions.

Same facility Medicaid admissions and equivalent admissions increased 9.1% and 12.7% respectively in the quarter, consistent with the trends we experienced in the third quarter.

We continue to see strength in our five expansion states, but also have seen growth in our non-expansion states as well.

I will provide additional comments on Medicaid in my health reform remarks.

Same facility self-pay and charity admissions declined 8.8% in the quarter, while equivalent admissions declined 4.6%.

These represent 7.2% of our total admissions compared to 8.3% last year and has continued to turn favorable for the company.

Managed care and other, which includes exchange admissions increased 5.3% and equivalent admissions increased 5.5% on a same-facility basis in the fourth quarter compared to the prior year.

Same-facility emergency room visits increased 10.5% in the fourth quarter compared to the prior year.

Same-facility, self-pay and charity ER visits represent a 19.7% of our total ER visits in the quarter compared to 23.2% last year.

Intensity of service or acuity continued to increase in the quarter, with our same-facility case mix increasing 0.7% comparing to the prior year period.

Same-facility surgical volumes increased 0.6% in the quarter, with same-facility inpatient surgeries increasing 2.4% and outpatient surgeries declining 0.3% from the prior year.

Same-facility revenue per equivalent admission increased 2.5% in the quarter.

Same-facility managed care and other, which includes exchanges, revenue per equivalent admission increased 3% in the quarter.

Consistent with our third quarter results, case mix increased 1.9% compared to the prior year.

Same-facility charity care and uninsured discounts increased $238 million in the quarter compared to the prior year.

Same-facility charity care discounts totaled $897 million, a decline of $18 million from the prior-year period, while same-facility uninsured discounts totaled $2.39 billion, an increase of $256 million over the prior year.

Now turning to expenses.

Expense management in the quarter was very good as we were able to leverage strong volumes and higher intensity of services.

Same-facility operating expense per equivalent admission increased 0.9% compared to last year's fourth quarter.

Salaries and benefits as a percent of revenue improved by 50 basis points to 44.4% compared to 44.9% in last year's fourth quarter.

Salaries per equivalent admission increased 1.8% in the quarter on a same-facility basis leveraging our strong volume in the quarter.

Supply expense per equivalent admission was flat for the fourth quarter compared to the prior-year period and improved 50 basis points as a percent of revenue from last year's fourth quarter, reflecting continued success on several supply chain initiatives.

Other operating expenses improved 10 basis points from last year's fourth quarter to 18.5% of revenues.

We recognized $28 million in electronic health record income in the quarter compared to $50 million last year.

Consistent with our expectations, we incurred approximately $16 million in electronic health expenses in the quarter compared to $28 million last year.

As previously mentioned our as reported adjusted EBITDA margins increased 90 basis points over the prior year.

Adjusting for Texas Waiver items, high tech income and share-based compensation, adjusted EBITDA margin increased 100 basis points over prior year for the quarter.

Let me touch briefly on cash flow.

We had another extremely strong quarter, with cash flow from operations increasing to $1.627 billion, 33% above last year.

At the end of the quarter, we had approximately $2.1 billion available under our revolving credit facilities.

For full year 2014, cash flow from operations was $4.45 billion and free cash flows were just over $1.8 billion.

So that concludes my remarks on 2014.

I'd like to turn the call over to Sam to give some additional detail for the quarter, and I'll come back and discuss health reform and our 2015 guidance.

Good morning.

As mentioned earlier, volume growth accelerated in the fourth quarter as compared to the previous three quarters of the year.

We believe this performance reflects a combination of solid execution of our growth agenda, our operating teams, improving macroeconomic trends in many of our markets, and capital spending that has been invested both to increase access to our networks and to add operational capacity.

There were some additional factors that contributed to the quarter's accelerating growth.

First, we had a return to normal seasonality trend.

Typically, fourth quarter volumes trends are over the third quarter by approximately 1.5%.

In 2013, this did not happen, which created a favorable comparison for 2014.

Secondly, admissions with the flu-related diagnosis were up 77%, which drove approximately 40 basis points of our overall growth.

And finally, the anniversary of the CMS 2-Midnight Rule occurred in this quarter.

These factors overlap somewhat, but I wanted to highlight them.

Growth in volume was broad-based across most of the company's market and it was also broad-based across the various service lines of our business.

On a year-over-year basis, for the quarter, all of our 14 domestic divisions had growth in admissions, both in adjusted admissions and growth in emergency room visits.

All but one of our divisions had growth in managed care and exchange admissions and adjusted admissions.

All divisions had growth in emergency room visits for these payer classes.

All of our divisions had growth in inpatient surgeries and 10 had growth in hospital-based outpatient surgeries.

Most of them had some level of surgical growth with notable growth in orthopedics, vascular and general surgery services.

Our Ambulatory Surgery Division had continued softness in the quarter.

Surgeries were down 2.6%.

Deliveries for the quarter were up 3.7%, with 10 divisions showing growth.

Managed care and exchange deliveries were up almost 11%.

All divisions had growth in these payer classes.

Other categories of our business were strong also.

Neonatal admissions grew 9.5%.

Behavioral health admissions were up 9%.

Rehab admissions were up 9.7%.

And finally, average length of stay grew about 0.9%, reflecting the higher case mix and acuity of our admissions.

Market share trends for the company for the 12 month period ended June 30, 2014, are generally consistent with past trends.

Market share grew by 10 basis points to slightly above 24%, with approximately 60% of our markets increasing share across most of the service line categories.

Of particular note is the rebound in overall inpatient demand, which increased in the second quarter across HCA's markets by slightly over 1%.

Commercial demand was even more notable, with an increase of 3.5%.

Demand in the prior two quarters of this 12 month period was down.

HCA has a comprehensive growth agenda that we believe is driving results.

We continue to invest in it at appropriate levels.

In 2015, we will be increasing our capital expenditures to around $2.4 billion.

This increase will provide more capital in our markets to add inpatient bed capacity, increase emergency room capacity and add equipment for our nurses and sergeants.

In certain markets, the capital spending will be deployed through new hospitals and new outpatient facilities.

In addition to the increasing capital spending, we are making investments in other aspects of our business and will require additional operating expenses in 2015.

We believe these investments are strategic and will have a positive impact for the company in the future.

The three months prominent investments are in the following areas.

First, the company is implementing a new human resource model, we call it oneHR, that will leverage the company's scale and consolidate certain administrative functions, such as recruiting and training.

Once implemented, we believe this effort will enhance our workforce and help our facilities deliver better care more efficiently.

The second area is related to our information systems.

The company is making additional investments for information system that we believe will provide a better user experience for our physicians.

Additionally, we expect these investments will create more robust clinical data that we can leverage across our business to improve quality, increase efficiencies and drive growth.

And finally, the company is making an investment to implement the new ICD-10 coding requirements, which go into effect later this year.

These operational initiatives plus a few smaller ones represent approximately $100 million in additional cost in 2015.

With that, let me turn the call back to Bill.

Thanks, Sam.

So now, let me move into a discussion about health reform and our 2015 guidance.

In the fourth quarter of 2014, we saw just over 7,700 exchange admissions and about 26,000 exchange ER visits.

This is about equal to our third quarter exchange volumes and fell in line with our expectations that exchange growth will level out in the second half of the year.

Our trends in Medicaid expansion states continued into the fourth quarter.

In the fourth quarter, Medicaid admissions were up 51% and uninsured admissions were down 65% in expansion states.

For full year 2014, Medicaid admissions and expansion states increased 40% and uninsured admissions were down 58%.

In non-expansion states, Medicaid admissions increased 3.3% and uninsured admissions declined 1.6% over prior-year's fourth quarter.

For the year, Medicaid admissions increased 2.4% and uninsured admissions declined 3.4% in our non-expansion states.

With only five states expanding Medicaid bill, the vast majority of reform benefit is still coming from the exchange activity.

The percentage of our exchange volume that was previously uninsured came down a bit in the fourth quarter.

And now year-to-date, based on our look-back, we estimate about 42% of exchange volume were newly insured for 2014.

When we rollup all aspects in reform, we estimate health reform contributed about 4.5% of adjusted EBITDA growth for us in 2014, and that's when you compare it to our 2013 adjusted EBITDA.

As we think about modeling, the 2015 reform benefit demonstrate there remain several variables that impact our assumptions and guidance and including final enrollment, the percentage of newly insured for the new enrolled lives, utilization trends and the impact of changing networks.

With all of these variables, we are currently estimating our reform benefit to increase approximately 60% to 70% from 2014 levels and represents 2% to 3% of incremental EBITDA growth over 2014, as reported EBITDA.

As a result, we estimate about 6% to 7% of our 2015 adjusted EBITDA will be related to the benefits of health reform.

Remember, these are benefits from increased coverage of the uninsured and are not being offset for these purposes by the (inaudible) reimbursement cuts to our annual CMS updates that we all experienced.

Our assumption on reform, in essence, starts with our current run rate and inflates for a growth factor that's principally keen on projected increases in total enrollment in exchanges, keeping our current experience for the assumption of newly insured about the same as 2014 and impact during a ramp up of utilization, similar to what we experienced this year.

There were a few other variables impacting our reform estimate, but we look at our growth principally by annualizing our current run rate and increasing for new enrollment activity.

There still remain some unknown variables that may impact the reform benefit.

So for now, this is our guidance going into 2015.

And consistent with our practices in 2014, our plan is to continue to update you on our experience, giving material changes in our thinking in conjunction with reporting our quarterly results.

Looking ahead for this year and our 2015 guidance.

Highlighted in our earnings release this morning, we estimated our 2015 consolidated revenue should range from $38.5 billion to $39.5 billion.

We expect adjusted EBITDA to be between $7.35 billion and $7.65 billion.

So let me walk you through how we think about our guidance.

First, as a management team, we view 2014, on all accounts as an outstanding year, one of our best years ever.

We were benefited not only by strong organic growth in health reform, but also a couple of non-recurring adjustments, and we highlighted these items within our release this morning.

Between the Texas waiver adjustments and RAC settlements alone, we recognized about $300 million of adjusted EBITDA in 2014 that we are not projecting to reoccur in 2015.

In addition, as anticipated, at around four year vesting schedule, our non-cash share-based compensation expense is projected to increase about $60 million in 2015.

Lastly is the continued step-down of our HITECH incentive income of about $80 million.

We are also indicating a decline of HITECH expenses and approximately $70 million of these costs remain in the company to continue to support electronic health vendors and other ongoing automation efforts.

Going forward, these costs are no longer being classified as HITECH expenses, but they remain in the system.

So when you adjust for these items, the $300 million of non-recurring adjustments, share-based comp and HITECH income declines.

The midpoint of our guidance reflects about 7.2% growth over 2014, which includes the 2% to 3% reform benefit, leading our core business growth between 4.5% and 5%.

Within our revenue estimates, we estimate equivalent admission growth to range between 2% and 3% for the year and revenue per equivalent admission growth to range between 2% to 4% for 2015.

We anticipate our Medicare revenues per equivalent admissions to reflect the composite growth rate of about 1%, factoring in market basket changes and offer reductions as well as some anticipated intensity increases.

Medicaid revenues per equivalent admissions are estimated being mostly flat year-over-year, excluding the declines of Texas Medicaid waiver revenues.

And managed and commercial revenues per equivalent admissions are estimated to grow between 4% and 5%.

Operating expenses are anticipated to continue to benefit from the continued low inflationary environment, and we are estimating large improvements to range between 20 basis points and 50 basis points on a normalized basis.

We anticipate capital spending to increase to $2.4 billion in 2015.

We estimate depreciation and amortization to be just under $1.9 billion and interest expense to be about $1.7 billion.

Our effective tax rate is expected to be about 38%.

And lastly, our average shares are projected to be approximately 442 million share and earnings per share guidance for 2015 is between $4.55 and $4.95.

So that concludes my remarks.

I'll turn the call over to Vic for some Q&A.

Bill, thank you.

Shanelle, if you could jump back on and poll for questions.

And we would encourage each of you to limit your questions to just one, because we have quite a number of folks on the line today and we'll give everybody a chance.

Thank you.

Today's question-and-answer session will be conducted electronically.

(Operator Instructions).

Josh Raskin, Barclays.

So I appreciate you guys delineating the EBITDA growth.

And I guess if I look at it now that sort of core growth, that you guys are talking about, the 4.5% to 5%, that actually screen toward the higher-end of, I guess, your 3% to 5% long-term organic growth.

So is that just economic recovery?

Does that include some of the outpatient growth and acquisitions that you guys are seeing?

It didn't sound like the volume growth is necessarily can be way above historical.

So I'm just curious, why you guys are more comfortable at that higher-end of the organic growth rate?

I'll start up with that and then Bill and Sam maybe want to add some comments.

Yes, it is at the higher-end of our 3% to 5% growth that we have been stating for a number of years now, which we expect certain years to obviously do a little bit better, maybe other years a little bit less, but we think that's a reasonable zone.

And we did guide to the high-end of that range this year.

Now, I think it's reflective of our marketplace, as you know, the capital that we're spending, we've increased our capital spend over the last couple of years.

Again, we're seeing a macroeconomic improvement in many of our markets.

We've talked about that over the last several months.

We're seeing our volume in that 2% to 3% range that we're guiding, coming off of year we were 2.9% this year for the year.

So we think all those things, the acquisitions we've made and some of the tuck-in acquisitions, the acquisition of CareNow, all those things providing us to I think come in a core growth near the top or at the top of our 3% to 5% expectation.

Justin Lake, JPMorgan.

So I wanted to dig in on the reform guidance for a minute.

Specifically, can you walk us through the run rate coming out of the fourth quarter?

And maybe also can you give us a ballpark estimate for the reform benefits in Q1 through Q3, just so we understand the run rate versus the new growth?

And then I had one quick numbers question.

Bill, that's all yours.

Let me try to walk you through it and do the best I can on it and I'll try to lay out some detail on the commentary.

As I look at reform, we said it contributed about 4.5% of our growth in 2014.

That clearly ramps in the second half of the year, leveled out to Q3 and Q4.

So a little bit higher towards the backend of that number you can estimate.

As we think about watching our reform, 2014 we saw a ramp up of volume, low in Q1, ramps through our Q2, and really leveled out in Q3 and Q4.

So a simple way we look at our estimate is, first, by annualizing our Q4 run rate, and that utilization makes up about half of our increase alone.

And then we're estimating the new enrollment numbers on top of that.

And I know we're all keeping an eye on this.

We're roughly keying off HHS total enrollment projection of around 10 million, up from 7 million or so in 2014.

That's obviously nationally, so we did try to make some assumptions and distract enrollments trends in our markets.

So keying off this, we potentially might see a 40% to 50% increase in total enrollment.

We don't expect to see that kind of volume increase day one, so we're back to our assumption on volume ramping through Q1 and Q2, and with this we might see an expected increase, let's say, 30% to 35% on top of our Q4 run rate.

So, yes, a large portion of that growth will be weighted towards Q1 and Q2, and then you might see that 30% or so growth overall run rates for the Q3 and Q4.

So year-on-year growth is probably a little bit between the first quarter and second quarter.

And half of it is coming from or half of the growth is coming from the utilization effect and the other half coming from our assumption around increased enrollment.

Justin you had one numbers question, you wanted to ask.

If you could give us cash flow from operations and minority interest numbers, that will be great.

I think cash flow from ops would be in a range of between $4 billion and $4.5 billion.

And I don't have minority interest handy (inaudible).

I'll get to you, Justin.

And we'll go next to A. J. Rice with UBS.

I guess I'll just ask about Texas Medicaid waiver and your assumptions there.

So you recognized, say, about $70 million in 2014, but it sound like for the last two quarters of the year you were getting about $34 million to $35 million a quarter.

I guess what is the run rate that you would say if you get these approvals that you'd see it in 2015?

And it sounds like there is some indication that you're going to get something, you just haven't pinned down exactly what the amount is.

Can you just confirm that and give us some flavor more or detail, as to what you're actually looking to see?

I know there are a lot of moving parts to this, so let me try to walk you through and simplify as best I can.

In the third quarter, due to inquiry and payment deferral, we reduced the Medicaid revenues and our related expected receivables that we have previously recorded, due to that uncertainty.

The Medicaid program is on a 10-month fiscal year, so our adjustments we booked in the third quarter really related to the September 30, 2014, yearend in what we have previously recorded.

As I mentioned, based on the activity we saw on the fourth quarter, the $161 million payment (inaudible) related to the 2014 fiscal year gave us confidence in restoring our estimate for that program here.

So what we're really talking about is reducing our revenue recognition for the program years in 2015 and potentially even 2016, depending on how the inquiry unfolds.

And so the reduced revenue is about $35 million in the fourth quarter and the effective reduce in our revenue recognition year-over-year is about $70 million from 2015.

So how I would think about it is, majority of that reduction that we're recognizing between 2015 and 2014 is because of some uncertainty around the inquiry on a go-forward basis.

We hope to have some insight and maybe even clarity on the extent of that inquiry going forward and will adjust that as necessary, but in essence what we're doing is reducing our revenue curve going forward in light of some of those ongoing inquiries going forward.

So I think $70 million is the number used year-over-year, and if that returns favorably, then we'll re-examine revenue that we should record going through the 2015 year.

We hope to have some insight and maybe even clarity on the extent of that inquiry going forward and will adjust that as necessary, but in essence what we're doing is reducing our revenue curve going forward in light of some of those ongoing inquiries going forward.

So I think $70 million is the number used year-over-year, and if that returns favorably, then we'll re-examine revenue that we should record going through the 2015 year.

Just want to follow up on the exchange benefit.

I guess the math that you laid out makes some sense.

Although, I think that Bill could have made it a little bit faster.

It just feels conservative.

Where does the 37% increase of exchange contracts fit into that analysis?

I would think that should be additive.

Or is there some offset on pricing or something else that we should be thinking about?

It is.

And Kevin, as I tried to mentioned, there is a lot of variables that go into it.

We try to simplify, just taking our run rate up by a level, and clearly we're factoring it in kind of new contracts, potentially new access.

There is also other factors that we talked about in the past, some potential current yield declines or payment declines, as you participate in some of those networks to slight degree, some in fact are Medicaid expansions.

So we've factored all of those variables into our estimate.

We're trying to just characterize by the run rate plus enrollment.

But it is being adjusted for both, the increased network participation and offset a little bit by some yield differentials in payments for the previously insured commercial product as compared to exchange product.

Andrew Schenker, Morgan Stanley.

Just following up once again on the exchange math here.

I do appreciate commentary on the 40% to 50% increase in enrollment, but last couple of quarters you guys talked about your expectations to increase your yield and converting your uninsured over to exchange rates and expenses in 2014.

Maybe if you could just touch upon how your experience is with those populations progress?

And any expectations, the uninsured may deviate in a positive way for you guys from versus maybe national expectations?

Andrew, we key off really what our current experience is and as we talked through before what we do is look back at exchange patients level we've seen this year, look back how we've previously seen them and what was their status when we saw them.

And that's what we're coming up with our estimate of about 42% on a yearly basis of the patients we saw in exchanges who are newly insured.

We're clearly keeping tack of various reports that are out there about year or two.

And one of the key variables will be -- is the new large in year two really be similar on a percentage newly insured, can they potentially be greater than the numbers in year one.

And we know that's a variable.

But our assumption right now is based on the best experience we have, which is what we're actually seeing.

As a corollary, maybe related to your question, we are making outreach efforts within our communities to help people explore gaining access to coverage.

And as we did talk about I think on our last quarter's call, we stepped up our efforts this year as compared to what we were doing last year.

We've partnered with several national agencies.

We've made a lot of outbound efforts in terms of e-mail, letters, even personal contact, helping people register within community events, and helping people explore access to coverage and made it available to them either through expanded Medicaid or health insurance changes.

I characterize those efforts as much better than we've had in year one.

We sometimes lose visibility in how much of those actually yielded in enrollment, but the patients that were new were very, very impressed that we were able to have some traction on the communities and for our previously uninsured patients that we serve.

So we probably know this is a variable keeping track of.

If it turns out national enrollment is more favorable than that, then our experienced kind of yields that.

Then I would hope our advantage is greater, but right now we're going on the assumption base than based on our actual experience.

Darren Lehrich with Deutsche Bank.

My question is in the context of Secretary Burwell announcing last week on HHS', obviously setting some I guess medium-term goals on alternative payment models.

And I was just hoping you could update us on where HCA is in terms of time, quality to payments and if there is a way to quantify now how much your revenue is contracted and any kind of alternative payment models beyond just the street fee-for service?

Milton, you want to take that?

Of course, Darren, we've been dealing with some paper performance elements in our Medicare reimbursement.

Now, for the last few years, we do well with that.

Of course, that's a small percentage of the overall Medicare revenue.

In our managed care contracts, many of our managed care have paper performance and those contracts typically impacts the amount of the annual increase, it maybe a 0.5% or a certain amount of the increased subject to achieving certain performance metrics.

And again, we perform well with those metrics.

When I talk about the bigger picture, the value in healthcare, and I mentioned this in my opening comments, we realize that with changes in healthcare, increasing consumers in the healthcare that we need to provide greater quality in service and value.

And so if you look at our agenda around quality, our agenda around patient service, our ability to deliver care efficiently, our facilities, the investments we're making in technology, all these things, clinical excellence, all these things I think are reflective of an organization that's focused on improving the outcomes and service to our patients and therefore providing more value for the healthcare dollar.

So I feel very comfortable that we're making the right investments to be able to operate effectively in an environment where it's, say, more value-based, based on quality outcomes and delivering value to the patients or to the payers or to the employers.

Today not a lot of our revenue quite frankly is subject to that.

Again, it's implemental in certain contracts.

But we are preparing the organization to be able to perform in that environment, if we see the marketplace change.

Number one, it's good business, it's what we should be focused on, quality and service to the patients, as I said is our number one priority and it will continue to be in the foreseeable future.

Gary Lieberman, Wells Fargo.

I guess maybe could you talk about your view on additional states expanding Medicaid.

Is any of that factored into your guidance?

And I guess which states you're most optimistic about potentially participating what the benefit might be?

In terms of factoring into guidance, we are only including the states that have expanded Medicaid.

So we're not making the guess on where others are.

We do have a small physician in Indiana and it appears that Indiana is moving forward, so that's very good moves.

Here in Tennessee you're probably all aware that a special session of the legislature began last night.

Governor Haslam is working very, very hard and many are working with him to try to help our state legislatures understand how important this is to the state of Tennessee and benefits that would accrue to many across states.

So we're hopeful and reasonably optimistically hope that that can get passed here early, but we have not put any of that into our numbers.

We'll obviously continue to watch other states and be supportive where we can be.

Any view on Florida specifically of what might happen there?

Probably your view is good as mine.

There are some who support it and some who don't and we don't necessarily think it happened this year, but your guess again would be as good as mine.

Ralph Giacobbe, Credit Suisse.

Capital deployment back to shareholders in the form of repurchase and even dividend at times has certainly been strong.

I guess the question is where do you sit with M&A?

Do you see longer assets emerging, is valuation perhaps centering deals?

And I guess what's the outlook and pipeline for maybe larger system consolidation?

Well, as I have said for the last several years, we're interested in the opportunity to grow through acquisitions have the right market dynamics, and recourse with the right pricing discipline.

Quite frankly we haven't seen a lot of opportunities, what I call needle-moving opportunities.

We've had a few, and in many cases, the seller decided not to pursue other transactions.

So we remain hopeful that we'll see some good opportunities.

But as I've said many times in the past if we don't have the opportunities to grow through acquisitions, we'll continue to invest in our existing markets and see our capital spend increase for 2015, up to about $2.4 billion.

We have opportunities to grow organically.

We've been doing that in recent years.

We'll continue to do that.

We're fortunate to have markets that are growing.

We're seeing some improvement in demand for services.

And again, with our growth strategies, we feel confident we can continue to have solid organic growth as expressed in our guidance for this year.

Also, with our strong cash flows, as Bill mentioned, we do have the opportunity to return cash to shareholders on a regular basis.

Most recently, we've been doing that with share repurchases the $1.75 billion that we accomplished in 2014, and this morning announcing another $1 billion share repurchase.

So we've had a very diverse capital deployment strategy since coming back into the public market in 2011.

And we will continue to do that.

We try to continue to take advantage of the opportunities that the market presents.

And use our balance sheet, the good position we have on our balance sheet appropriately to increase shareholder value.

If I could add one thing to that, we have been fairly active in outpatient acquisitions and other type of facility acquisitions that complement our networks within each of our markets and we'll continue to be opportunistic in that particular area, because it's very accretive to the local market and it creates better platform for our provider systems locally.

And no, that opportunities are not material in and of themselves, but they do add value over time and create different relationships with patients and different relationships with physicians.

Frank Morgan, RBC Capital Markets.

Most of mine have been answered, but I guess I've got one here for Bill going back to the guidance.

I know there are a couple of things that I kind of picked up on, that might be upside.

But from your perspective, where do you see the biggest wiggle room, the biggest drivers to either getting the high end of your range or maybe even exceeding it?

I'll try not to walk into something.

I think we tried to walkthrough really some of the moving parts that we have prepared for 2015 and 2014.

And that puts us, as I think mentioned before, at high end of our traditional range of 3% to 5%, perhaps a little bit lower than what we posted in the past year or so.

So reform, clearly, I would tell you there is still remain variables on reform.

It turned out better throughout 2014, and we anticipate it going into 2014, but there's so many variables that go into it.

It's our operational trends, volumes and rates as well as how some of these kind of moving parts unfold on us.

And I think there is more probably right now has some of the most variability to it.

Brian Tanquilut, Jefferies.

Just a follow-up on Frank's question and to your answer to that one, Bill.

At your Medicaid expansion state ER visits for the uninsured, what's the trend that you're seeing so far?

Are you still seeing improvements throughout, that where we ended in Q4?

Yes.

So in our expansion states, it's leveled off.

We saw the majority of the benefit in the third quarter in the state.

The uninsured declines in our expansion states are still in that 60% level, so we're kind of leveled off at that.

So I'd say they have found their level right now.

I think that's contributed significantly to the company's overall uninsured trends.

And I'm not so sure what we'll see in a year two in those expansion states in terms of the year-over-year growth.

I think there is probably still some more room for uninsured to gain access to coverage in year two in those expansion states.

Clearly it won't be as dramatic as we experienced this year.

So I think for the most part, it probably found its level.

We seem to be in the fourth quarter about where we were in third quarter.

So we might see some incremental benefit going into the year with more uninsured gain couch in those expansion states, but its still 60% to 65% decline that we saw in the fourth quarter.

Chris Rigg, Susquehanna Financial Group.

This is kind of a follow-up to the last question, but historically the industry has talked about frequent [players] and more population representing kind of a disproportionally high level of the bad debt.

I guess, particularly in the Medicaid expansion states, but also among those that you presume to be newly covered or under commercial subsidiaries, have you seen any behavioral changes from the population?

Have they come into the ER less or anything notable to highlight would be great.

The remaining uninsured, I can't say I've seen anything different in their behavior.

We have identified that cliff, and our outbound efforts this year were trying to help people, in that situation understand access and availability that walk in for coverage.

But I don't think we've seen any change in their behavior.

Let me add one thing to that.

On the Medicaid side, I think that's entirely the case.

We haven't really seen a significant change in Medicaid activity and behavior.

So the emergency room heavily, they struggle to get access to physicians in some markets.

So that dynamic still exists.

On the uninsured, who have gained access to commercial insurance products, we have seen less utilization of the emergency room and more availability to other facility opportunities or physician opportunities.

And that's been slight, but significant enough for us to notice that when they do get commercial insurance, there is different ability to access care through physician office or possibly through urgent care centers and the like and not through the emergency room.

So that has been noticeable.

Is it material yet?

No.

Could it possible develop over time?

And again, that's part of the reason we are looking at other alternative facility acquisitions and development in urgent care and so forth, so that we're prepared for that dynamic, if in fact it does occur.

Ana Gupte, Leerink Partners.

So just could you give a little bit more color on the volumes trends and what you're assuming in your guidance for 2015?

Specifically, on the HCA, with the existing enrollment that you have, what types of volume assumptions have you made with regard to the surgeries and procedures and so on depending on the health risk you've seen.

Any color on the economy as far as what you're assuming on either changing trends or unemployment?

And then finally on, any shifts you might have seen on Ebola and the flu that I think you 40 bps, what is the assumption being made for the 2015 guidance?

Let me try to address the first part.

As we mentioned, our overall volume guidance is 2% to 3% of equivalent admission growth for the year.

You asked specifically around health reform volume contribution to that, we alluded to kind of our health reform build to 50% to 60% year-over-year, a little bit north of that.

That is reflecting equalization of the growth, principally in the Q1 and Q2 time, and then anticipating on an average basis about 30% to 35% growth in enrollment.

So that has helped fueling some of our increased volume growth for the company.

Sam, I'll let you comment on the economic.

I think if you do short circuit, the volume assumptions at the company had build into its 2015 play and its 2015 guidance.

It's really on the particular point.

First is that we do think that the market play is going to revert back to sort of normal demand growth.

In some of that is the macroeconomic picture, but some of it is normalized activity with respective [plus] and so forth as we've seen from one quarter to the other.

So that's going to generate we think, somewhat between the half of point of growth in overall demand.

And then if you look at our market share trends, over the past 24 to 36 months, we've tended to pick up 20 basis points to 25 basis points in market share maybe as a good metric over time.

So when you put that together, it puts us in the range of our volume guidance.

We have numerous initiatives that should drive growth into marketplace, and Milton touched on them, it revolves around creating sufficient access points to our networks, so that patients can find it convenient to enter into an HCA network.

So we have significant investments in additional outpatient access points.

In 2015, that will hit the marketplace.

Additionally, we are making sure that our networks within each of our markets have a comprehensive array of service line, so that they can take care of a patient, if needed within any particular service line somewhere within our network.

Again, we're adding capability there with different kind of service line offering there both deeper income statement and broader in others.

And then the third piece is related to our physician strategy, when we're working with our physicians to add physicians to our medical staff or to create better alignment through different technologies and different relationships and so forth, and that we believe is rounding out the growth strategy.

So if you underpin that with more capital going into the market, we think those are the basic elements that will continue to support market share gains and industry-leading growth.

We're closing in on the hour, so one last question.

Gary Taylor, Citi.

I didn't hear you say much about Texas and maybe I missed that earlier, but just maybe some thoughts on anything you've seen in the quarter.

The Texas economy, obviously, energy dependent to some degree, and then how that factored in 2015 if you're anticipating to see some weaker results in Texas?

In short, we have evaluated the effects of the energy economy, if you will, and what implications it presents for us in Texas.

In Texas, economy we believe is significantly more diversified today than it was in years past.

Having said that, the Houston market, in particular, is the market that's most susceptible we believe to the energy dynamics are up, but in the face of all of that we've done the diversification in Houston as well.

And our overall believe is in 2015, we're not going to have a dramatic impact on trends in Texas.

And so we have not factored in any kind of significant trend change in any of our markets with respect to our assumptions in those particular cities.

Again, Houston is the most impacted we believe and we think our strategies are very solid there, and we'll be able endure some modest change in their economy.

And that has been one of the better economies across HCA, when you look market activity and economic growth and so forth.

Houston, that's obviously the most significant economy by itself.

And you do see that reducing, but the effect of that is not going to be material.

Thank you everyone and we look forward to hearing from you.

And Mark will be here all day, if you're willing to chat.

Thank you and have a great week

That does conclude today's conference.

Thank you for your participation.