美國醫院公司 (HCA) 2023 Q2 法說會逐字稿

Welcome to the HCA Healthcare Second Quarter 2023 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 Vice President of Investor Relations, Mr. Frank Morgan. Please go ahead, sir.

歡迎參加 HCA Healthcare 2023 年第二季度收益電話會議。今天的通話正在錄音。現在，我想將電話轉給投資者關係副總裁弗蘭克·摩根先生進行開場發言和介紹。請繼續，先生。

Good morning, and welcome to everyone on today's call. With me this morning is our CEO, Sam Hazen; and CFO, Bill Rutherford. Sam and Bill will provide some prepared remarks, and then we will take questions.

早上好，歡迎大家參加今天的電話會議。今天早上和我在一起的是我們的首席執行官 Sam Hazen；和首席財務官比爾盧瑟福。薩姆和比爾將提供一些準備好的發言，然後我們將回答問題。

Before I turn the call over to Sam, 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. More information on forward-looking statements and these factors are listed in today's press release and in our various SEC filings.

在我將電話轉交給 Sam 之前，讓我提醒大家，今天的電話會議是否包含任何前瞻性陳述，它們都是基於管理層當前的預期。許多風險、不確定性和其他因素可能導致實際結果與今天可能表達的結果存在重大差異。有關前瞻性陳述和這些因素的更多信息已在今天的新聞稿和我們向 SEC 提交的各種文件中列出。

On this morning's call, we may reference measures such as adjusted EBITDA, which is a non-GAAP financial measure. A table providing supplemental information on adjusted EBITDA and reconciling net income attributable to HCA is included in today's press release. This morning's call is being recorded, and a replay of the call will be available later today.

在今天早上的電話會議上，我們可能會參考調整後 EBITDA 等指標，這是一項非 GAAP 財務指標。今天的新聞稿中包含了一份表格，提供了調整後 EBITDA 和調節 HCA 淨利潤的補充信息。今天早上的通話正在錄音，今天晚些時候將提供通話重播。

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

現在，我將把電話轉給 Sam。

Good morning. Thank you for joining the call. The company produced solid earnings in the second quarter. These results reflected continued strong demand for our services and healthy operating margins. Across most areas of our business, we maintain the operational momentum that we experienced over the past 3 quarters. We believe this strength should continue into the second half of the year. Accordingly, we updated our earnings guidance for 2023 to reflect this outlook.

早上好。感謝您加入通話。該公司第二季度盈利穩健。這些結果反映了對我們服務的持續強勁需求和健康的營業利潤率。在我們業務的大部分領域，我們保持了過去三個季度的運營勢頭。我們相信這種強勁勢頭應該會持續到今年下半年。因此，我們更新了 2023 年的盈利指引以反映這一前景。

Against the difficult comparison to the second quarter of 2022, and diluted earnings per share increased to $4.29. Same-facility volumes across the company were strong. Admissions grew 2.2% year-over-year, inpatient surgeries increased 1.8%, same facility equivalent admissions increased 3.7%. This growth was driven by emergency room visits, which grew 3.7% and outpatient surgeries which grew 3.3%. Other outpatient categories also grew, including outpatient cardiology procedures which increased 5%. The growth in volumes was broad-based across the company's divisions and diversified within most service lines.

與 2022 年第二季度的艱難比較相比，稀釋後每股收益增至 4.29 美元。整個公司的同一設施容量強勁。入院人數同比增長 2.2%，住院手術人數增長 1.8%，同等設施同等入院人數增長 3.7%。這一增長是由急診就診人數增長 3.7% 和門診手術人數增長 3.3% 推動的。其他門診類別也有所增長，其中門診心髒病手術增長了 5%。公司各個部門的銷量增長廣泛，並且大多數服務線都實現了多元化。

Additionally, volumes were supported by strong acuity growth of 1.6% and a favorable payer mix from commercial adjusted admissions growth of 5%. These factors drove an increase in same-facility revenue of 6.3% as compared to the prior year.

此外，1.6% 的強勁增長以及 5% 的商業調整後入場人數增長帶來的有利支付組合也為銷量提供了支撐。這些因素推動同設施收入較上年增長 6.3%。

In the quarter, we continued to invest in our people, and as a result, we saw improvements across virtually all key labor metrics. Turnover continued to decline for nurses and trended at an annualized rate of 17%. Nurse hiring remained strong in the quarter and for the year has increased by 9% as compared to last year. These positive results helped reduce contract labor costs 20% compared to the second quarter last year.

本季度，我們繼續對員工進行投資，因此，幾乎所有關鍵勞動力指標都得到了改善。護士流動率持續下降，年化增長率為 17%。本季度護士招聘依然強勁，全年護士招聘比去年增加了 9%。與去年第二季度相比，這些積極成果幫助合同勞動力成本降低了 20%。

During the quarter, we improved available bed capacity, instances where we could not accept patients from other hospitals declined and represented 0.8% of total admissions, down from 1.5% in the first quarter. We believe the significant investments we are making in our networks, our people and our technology agenda will provide us with the necessary resources to improve our services and provide even higher quality care to our patients. As we look to the future, we remain encouraged by both the backdrop of strong demand that we expect in our markets and our overall competitive positioning within them.

本季度，我們改善了可用床位容量，無法接收其他醫院患者的情況有所減少，佔總住院人數的 0.8%，低於第一季度的 1.5%。我們相信，我們對網絡、人員和技術議程進行的重大投資將為我們提供必要的資源，以改善我們的服務並為患者提供更高質量的護理。展望未來，我們對市場預期的強勁需求以及我們在市場中的整體競爭地位感到鼓舞。

HCA Healthcare will continue to use its disciplined operating culture to execute our strategic and capital allocation plans. I want to thank our colleagues for their dedication and their overall effectiveness.

HCA Healthcare 將繼續利用其嚴謹的運營文化來執行我們的戰略和資本分配計劃。我要感謝我們的同事的奉獻精神和整體效率。

So let me close with this. I want to speak to a recent event that we take very seriously. On July 10, we announced that we had recently discovered a list of certain information with respect to some of our patients, was made available by an unknown and unauthorized party on an online forum. We have confirmed that the list does not include clinical information, payment information or other sensitive information like passwords, drivers license or social security numbers. Our forensic investigation is ongoing, but this event appears to be a theft from an external storage location that was exclusively used to format e-mail messages.

讓我以這個結束。我想談談最近發生的一件我們非常重視的事件。 7 月 10 日，我們宣布，我們最近發現了有關我們部分患者的某些信息列表，這些信息是由未知且未經授權的一方在在線論壇上提供的。我們已確認該列表不包括臨床信息、付款信息或其他敏感信息，如密碼、駕駛執照或社會安全號碼。我們的取證調查正在進行中，但此事件似乎是專門用於格式化電子郵件的外部存儲位置的盜竊事件。

We are in the process of notifying all affected patients in accordance with our legal and regulatory obligations. And not unexpectedly, we have been named as a defendant in multiple class action lawsuits. This incident has not caused any disruption to our day-to-day operations nor do we believe it will materially impact our business or financial results. HCA Healthcare believes the privacy of its patients is a vital part of its mission and remains committed to maintaining the security of their personal information.

我們正在根據我們的法律和監管義務通知所有受影響的患者。不出所料，我們在多起集體訴訟中被列為被告。這一事件並未對我們的日常運營造成任何干擾，我們也不認為它會對我們的業務或財務業績產生重大影響。 HCA Healthcare 認為患者的隱私是其使命的重要組成部分，並始終致力於維護患者個人信息的安全。

With that, I will turn the call to Bill for more details on the quarter's results.

接下來，我將致電比爾，了解有關本季度業績的更多詳細信息。

Great. Thank you, Sam, and good morning, everyone. I will provide some additional comments on our performance for the quarter.

偉大的。謝謝你，薩姆，大家早上好。我將對我們本季度的業績提供一些額外的評論。

Consolidated net revenue increased 7% to $15.86 billion from $14.82 billion in the prior year period. This was driven by 4% growth in equivalent admissions and 2.9% increase in revenue per equivalent admission. We remain pleased with our team's management of operating costs even with the backdrop of inflation. Our consolidated adjusted EBITDA margin was 19.3% in the quarter. During the quarter, we completed our transaction to acquire a majority stake in the Valesco joint venture and we are now consolidating the operations of this venture. This reduced our consolidated margins approximately 30 basis points in the quarter.

合併淨收入從上年同期的 148.2 億美元增長 7% 至 158.6 億美元。這是由同等入場人數增長 4% 和每等入場收入增長 2.9% 推動的。即使在通貨膨脹的背景下，我們仍然對我們團隊的運營成本管理感到滿意。本季度我們的綜合調整後 EBITDA 利潤率為 19.3%。本季度，我們完成了收購 Valesco 合資企業多數股權的交易，目前我們正在整合該企業的運營。這使我們本季度的綜合利潤率下降了約 30 個基點。

We believe this transaction not only mitigates business risk with the Envision bankruptcy proceedings but will also further support alignment between our hospital-based physicians and our hospital care teams on improving quality, patient satisfaction, and efficiencies. When you consider this transaction and the $145 million payer settlement we recognized last quarter, our adjusted EBITDA margins have remained consistent between the first and second quarters.

我們相信，這項交易不僅可以降低遠景破產程序帶來的業務風險，還將進一步支持我們的醫院醫生和醫院護理團隊在提高質量、患者滿意度和效率方面的協調一致。當考慮到這筆交易以及我們上季度確認的 1.45 億美元付款人和解金時，我們調整後的 EBITDA 利潤率在第一季度和第二季度之間保持一致。

So let me speak to some cash flow and capital allocation metrics as they remain a key part of our long-term growth and value creation strategies. Our cash flow from operations increased $845 million in the quarter from $1.63 billion in the prior year to $2.475 billion this year. Capital spending was just over $1.2 billion. We paid $164 million in dividends and repurchased $915 million of our stock during the quarter. Our debt to adjusted EBITDA leverage ratio remains near the low end of our stated leverage range of 3 to 4x.

因此，讓我談談一些現金流和資本配置指標，因為它們仍然是我們長期增長和價值創造戰略的關鍵部分。本季度我們的運營現金流增加了 8.45 億美元，從去年同期的 16.3 億美元增至今年的 24.75 億美元。資本支出剛剛超過 12 億美元。本季度我們支付了 1.64 億美元的股息，並回購了 9.15 億美元的股票。我們的債務與調整後 EBITDA 槓桿比率仍接近我們規定的 3 至 4 倍槓桿範圍的低端。

As noted in our release this morning, we are updating our full year 2023 guidance as follows: We expect revenues to range between $63.25 billion and $64.75 billion. We expect net income attributable to HCA Healthcare to range between $4.9 billion and $5.255 billion. We expect full year adjusted EBITDA to range between $12.3 billion and $12.8 billion. We expect full year diluted earnings per share to range between $17.70 and $18.90, and we expect capital spending to approximate $4.7 billion during the year.

正如我們今天上午發布的新聞稿中所指出的，我們將 2023 年全年指引更新如下：我們預計收入將在 632.5 億美元至 647.5 億美元之間。我們預計 HCA Healthcare 的淨利潤將在 49 億美元至 52.55 億美元之間。我們預計全年調整後 EBITDA 將在 123 億美元至 128 億美元之間。我們預計全年攤薄後每股收益將在 17.70 美元至 18.90 美元之間，我們預計年內資本支出約為 47 億美元。

So with that, I'll turn the call over to Frank and open it up for Q&A.

因此，我會將電話轉給弗蘭克並進行問答。

Thank you, Bill. (Operator Instructions) Bailey, you may now give instructions to those who would like to ask a question.

謝謝你，比爾。 （操作員指示）Bailey，您現在可以向那些想要提問的人發出指示。

(Operator Instructions) And your first question comes from A.J. Rice with Credit Suisse.

（操作員說明）您的第一個問題來自 A.J.瑞信的大米。

Maybe just -- I know Sam in his prepared remarks said that performance was solid across divisions. I wondered, there's been some discussion this quarter about Florida and Texas had come back early and had enjoyed strong volume. Now the rest of the country is rebounding. I wonder if you could comment on that. There was also a discussion from some of the managed care guys about particularly seeing strength in Medicare, Medicare Advantage and some pent-up demand being unleashed there. I wondered if you would comment on whether you're seeing any of that as well.

也許只是——我知道薩姆在他準備好的講話中說，各個部門的表現都很穩定。我想知道，本季度有一些關於佛羅里達州和德克薩斯州提前回歸併享受強勁交易量的討論。現在該國其他地區正在反彈。我想知道你是否可以對此發表評論。一些管理式醫療人員還進行了討論，特別是看到醫療保險、醫療保險優勢的優勢以及一些被壓抑的需求正在被釋放。我想知道您是否也看到了這些，對此發表評論。

All right. Thank you, A.J. As I mentioned in my comments, our volume growth was broad-based across our divisions. I think we had 13 out of 16 divisions in the company that had admission growth and adjusted admission growth. We clearly have some divisions that don't perform the same pretty much every quarter, but it was fairly broad-based across top line metrics, admissions, adjusted admissions, payer mix improvements and so forth. So a fairly consistent performance.

好的。謝謝你，A.J.正如我在評論中提到的，我們各個部門的銷量增長基礎廣泛。我認為公司 16 個部門中有 13 個部門實現了准入增長並調整了准入增長。顯然，我們有一些部門每個季度的表現都不盡相同，但在營收指標、招生、調整後的招生、付款人組合改進等方面的表現相當廣泛。所以表現相當一致。

We did have a couple of divisions that struggled, but one was isolated in Florida. The other one was isolated more out west in the Midwest. And so for the most part, we were really pleased with the overall performance that we had across the geographies of the company. And it's interesting, I was looking at something yesterday. We have, from an admission standpoint, almost 72% of our hospitals have greater than 2% admission growth for the year, and this includes a little bit of pressure from COVID in the first part of the year from a comparison standpoint.

我們確實有幾個部門陷入困境，但其中一個部門在佛羅里達州是孤立的。另一個則更偏僻，位於中西部西部。因此，在很大程度上，我們對公司在各個地區的整體表現感到非常滿意。很有趣，我昨天在看一些東西。從入院的角度來看，我們幾乎 72% 的醫院今年的入院增長率超過 2%，從比較的角度來看，這包括今年上半年新冠疫情帶來的一些壓力。

We have very significant performance from the surgery standpoint as well, where almost 50% of our hospitals have inpatient surgery growth above 2%. So really consistent portfolio performance that speaks to the strength of our markets, I think the competitive positioning of our facilities and then the ongoing network development and physician development that we have as part of our core strategy.

從手術角度來看，我們的表現也非常顯著，我們近 50% 的醫院的住院手術增長率超過 2%。因此，真正一致的產品組合表現體現了我們市場的實力，我認為我們設施的競爭定位，以及作為我們核心戰略一部分的持續網絡發展和醫生髮展。

The next question comes from the line of Ben Hendrix with RBC Capital Markets.

下一個問題來自加拿大皇家銀行資本市場的本·亨德里克斯 (Ben Hendrix)。

With regard to your updated guidance, can you provide some more color on what you're assuming for SWB, supplies and other operating expense, particularly professional fees through the second half versus what you've seen thus far this year? And then anything to call out that would alter a typical cadence through the second half?

關於您更新的指導，您能否提供更多關於您對 SWB、用品和其他運營費用（特別是下半年的專業費用）與今年迄今為止所看到的情況的假設？那麼有什麼可以改變下半場典型節奏的事情嗎？

Yes, Ben, this is Bill. Let me start. I think our updated guidance reflects what we're reserving -- observing in the market on our year-to-date performance, which continue

是的，本，這是比爾。讓我開始吧。我認為我們更新的指導反映了我們所保留的內容——在市場上觀察我們今年迄今的表現，這將繼續

(technical difficulty)

（技術難度）

in the growth opportunities. I think net-net, when I think about the margin profile of the company between the first half and the second half of the year, we'd expect the margin profile to be slightly better in the second half of the year. I think our salary, wages and benefits as a percent of revenue will run mostly where they're running year-to-date. Same with supplies. We have seen a little pressure on the professional fees. And we don't think that same pressure will exist in the balance of the year but will be able to manage through that.

在增長機會中。我認為淨淨，當我考慮公司上半年和下半年的利潤狀況時，我們預計下半年的利潤狀況會稍微好一些。我認為我們的薪水、工資和福利佔收入的百分比將主要與今年迄今為止的情況保持一致。與供應品相同。我們看到專業費用面臨一些壓力。我們認為今年剩餘時間不會存在同樣的壓力，但我們能夠應對。

The next question comes from Whit Mayo with Leerink Partners.

下一個問題來自 Leerink Partners 的 Whit Mayo。

Maybe just a question around labor. I think I heard you say, Bill, that contract labor improved maybe 20% year-over-year. Did it change much throughout the quarter? Just trying to get a sense of maybe the exit rate and expectations for the second half of the year?

也許只是關於勞動力的問題。我想我聽到你說，比爾，合同工同比增長了 20%。整個季度變化大嗎？只是想了解一下下半年的退出率和預期嗎？

Yes, Whit. I mean, we're pleased with the labor environment. We did mention our contract labor is down 20% versus the prior year. It's improved as well sequentially between Q2 and Q1. Our hiring metrics are up, turnover is down. And I think that portends good things for us going through the balance of the year.

是的，惠特。我的意思是，我們對勞動環境感到滿意。我們確實提到我們的合同工比去年減少了 20%。從第二季度到第一季度，它也依次得到改善。我們的招聘指標上升，人員流動率下降。我認為這對我們度過今年剩下的時間來說是好事。

We mentioned before, our contract labor cost as a percentage of our SWB was under 7% -- I think it was 6.8% in the quarter. So again, I think we're pleased with that, especially as we go through the summer months, some of our hires get through kind of their orientation process and that we get into the balance of the year, we would expect some continued improvement.

我們之前提到過，我們的合同勞動力成本佔 SWB 的百分比低於 7%——我認為本季度為 6.8%。再說一次，我認為我們對此感到滿意，特別是當我們經歷夏季的時候，我們的一些員工完成了他們的入職培訓，並且我們進入了今年的剩餘時間，我們預計會有一些持續的改進。

The next question comes from Gary Taylor with Cowen.

下一個問題來自加里·泰勒和考恩。

Just 2 quick ones for me. Bill, I might have missed it, but I know often you kind of run through some of the managed care metrics on admissions -- adjusted admission and surgeries, I wondering if you could rattle off a few of those for us?

對我來說只有 2 個快速的。比爾，我可能錯過了，但我知道您經常會瀏覽一些關於入院的管理式醫療指標——調整後的入院和手術，我想知道您是否可以為我們逐一介紹其中一些？

And then secondly, I just want to make sure I understood on the Envision joint venture, I think we were thinking that was maybe roughly $250 million of revenue. But do all the expenses lie in the SWB line? Is that where those reside down to kind of a roughly EBITDA breakeven?

其次，我只是想確保我了解遠景合資企業，我認為我們認為這可能是大約 2.5 億美元的收入。但所有的費用都在SWB線嗎？這是否就是 EBITDA 大致達到盈虧平衡的地方？

Yes. Gary, let me start with that. Some of our managed care, I think as we mentioned and the -- Sam mentioned in the comments, really favorable payer mix. Our managed care admissions were up over 4% in the quarter. Adjusted admissions were 5%. I think we mentioned that in our prepared comments. Emergency visits managed care were up 9.8% in the quarter, and again, good acuity of case mix growth. So we're really pleased with the payer mix that we're seeing, and that showed itself in the commercial trends. Relative to the Valesco joint venture, your numbers are really close. About 70% to 75% of the revenue is in SWB and the rest is in other operating. And you're right, it's basically a breakeven proposition a little north of $220 million of revenue that we had in the quarter as we consolidated that.

是的。加里，讓我從這個開始。我認為，正如我們所提到的，以及 Sam 在評論中提到的，我們的一些管理式醫療服務確實是非常有利的付款人組合。本季度我們的管理式醫療入院人數增長了 4% 以上。調整後的錄取率為5%。我想我們在準備好的評論中提到了這一點。本季度緊急就診管理式醫療增長了 9.8%，病例組合增長的敏銳度再次提高。因此，我們對所看到的付款人組合非常滿意，這在商業趨勢中得到了體現。相對於 Valesco 合資企業，你們的數字非常接近。大約 70% 至 75% 的收入來自 SWB，其餘來自其他業務。你是對的，這基本上是一個盈虧平衡的提議，略高於我們本季度合併後的 2.2 億美元收入。

And your next question will come from Justin Lake with Wolfe Research.

您的下一個問題將來自沃爾夫研究中心的賈斯汀·萊克。

Question on the pricing in the quarter. So with strong acuity and strong and strong payer mix, maybe can you remind us, is there anything in the second quarter that I might have slipped that, drove the pricing? I would have expected it to be a little bit better given those mix items and strong commercial pricing.

關於本季度定價的問題。因此，憑藉敏銳的洞察力和強大的付款人組合，也許您可以提醒我們，第二季度是否有什麼事情我可能會忽視，從而推動定價？考慮到這些混合項目和強勁的商業定價，我本以為它會好一點。

And then, Bill, can you just give us what you expect in the back half of the year for volumes with that updated guidance?

然後，比爾，您能否告訴我們您對今年下半年的銷量以及更新後的指導的預期？

Yes. Justin, nothing specific, we'll call out. I mean, obviously when we do year-over-year comparisons, COVID was still an impact for us. We had roughly $40 million of COVID support payments last year that we don't have this year. Our COVID admissions were 3% of total last year, roughly 1%. So that's still influencing a little bit on the revenue line. On our volume projections for the balance of the year, I think we'll be largely consistent. We've seen thus far, our year-to-date admissions same-facility are about 3.3%.

是的。賈斯汀，沒什麼具體的，我們會打電話說。我的意思是，顯然當我們進行同比比較時，新冠疫情仍然對我們產生影響。去年我們收到了大約 4000 萬美元的新冠肺炎支持金，但今年沒有了。去年，我們的新冠肺炎入院人數佔總人數的 3%，大約為 1%。所以這仍然對收入產生一些影響。關於我們對今年剩餘時間的銷量預測，我認為我們將基本保持一致。到目前為止，我們今年迄今的同類設施錄取率約為 3.3%。

I would think for the full year, we hover around 3% as well for the balance of the year. Our adjusted admissions year-to-date are 5.6%. I would think by the time we finish full year, it's still 5% to 6% adjusted admissions. So I think the volume trends we would expect in the second half of the year will be pretty consistent with what we've seen in the first half of the year.

我認為全年的增長率也徘徊在 3% 左右，而今年的剩餘時間也是如此。今年迄今調整後的錄取率為 5.6%。我認為，當我們全年結束時，招生人數仍然會有 5% 到 6% 的調整。因此，我認為我們預計下半年的銷量趨勢將與上半年的情況非常一致。

And the next question will come from Pito Chickering with Deutsche Bank.

下一個問題將由德意志銀行的 Pito Chickering 提出。

As I look at the implied revenue raise and EBITDA raise at the back half of the year, I'm trying to understand the flow-through of how much revenue raises should flow through into EBITDA upside. So how is it tracking in sort of 2023 versus sort of pre-COVID years?

當我查看今年下半年的隱含收入增長和 EBITDA 增長時，我試圖了解有多少收入增長應流入 EBITDA 上升。那麼 2023 年的情況與新冠疫情之前的情況相比如何呢？

Well, when I think about that, when I look at the raise, it's based on where we perform them in our view of the position going forward. We do expect continued improvement in the labor market. But as I said, I think as a percent of revenue, we hold, I think the margin profile overall for the second half of the year will be slightly better than the margin profile we saw in the first half of the year.

好吧，當我想到這一點時，當我考慮加薪時，它是基於我們對未來職位的看法而執行的。我們確實預計勞動力市場將持續改善。但正如我所說，我認為，從占收入的百分比來看，我們認為下半年的總體利潤率狀況將略好於我們上半年看到的利潤率狀況。

And that, all in all, has contributed in to the guidance raise. I remind you, we've raised our guidance almost the midpoint of our EBITDA guidance, roughly $450 million from where we turn the calendar. So I think all that's reflective in our considerations right now.

總而言之，這對指導意見的提高做出了貢獻。我提醒您，我們已將指導值上調至 EBITDA 指導值的中點，大約為 4.5 億美元。所以我認為所有這些都反映了我們現在的考慮。

Yes. And Bill, let me add a point here. I think it's a relevant point. Obviously, we've dealt with a fairly unprecedented labor market over the last 3 years or so. And we do believe, as Bill indicated earlier, it's moderating. We've also dealt with sort of an unprecedented hospital-based physician dynamic at a macro level. And if you just take a snapshot of where we are 6 months into this year versus where we were pre-pandemic when neither of these macro forces were in place, we've actually increased our margins by comparison to 2019.

是的。比爾，讓我在這裡補充一點。我認為這是一個相關的觀點。顯然，在過去三年左右的時間裡，我們面臨著前所未有的勞動力市場。正如比爾早些時候指出的那樣，我們確實相信這種情況正在放緩。我們還在宏觀層面上處理了前所未有的醫院醫生動態。如果你簡單地看一下今年 6 個月以來的情況與大流行前這些宏觀力量都沒有到位時的情況，就會發現與 2019 年相比，我們的利潤率實際上有所提高。

So I think it's sort of a testament to the ability of the company to adjust operationally to dynamics and continue to move forward with our strategy. As we've mentioned before, we think our competitive positioning has improved compared to where we were pre-pandemic.

因此，我認為這證明了公司有能力根據動態調整運營並繼續推進我們的戰略。正如我們之前提到的，我們認為與大流行前相比，我們的競爭地位有所改善。

Our market share has also improved during that time period. So we continue to believe that the company has the wherewithal to adjust to these factors, continue to move ahead in a very positive way and generate the results that we all want.

在此期間，我們的市場份額也有所提高。因此，我們仍然相信該公司有足夠的資金來適應這些因素，繼續以非常積極的方式前進並產生我們都想要的結果。

And your next question comes from Ann Hynes with Mizuho Group.

您的下一個問題來自瑞穗集團的安·海因斯。

I know it's early, but do you have any observations on how Medicaid determinations is impacting your business? I know one of your bigger states, Texas, started early. It sounds like it's been a little bit messy. So any early observations? And can you remind us if you have anything from the Medicaid redeterminations in your guidance? And do you think this process is going to be an overall positive or negative for HCA?

我知道現在還為時尚早，但是您對醫療補助決定如何影響您的業務有什麼觀察嗎？我知道你們較大的州之一德克薩斯州很早就開始了。聽起來好像有點亂了。那麼有什麼早期觀察嗎？您能否提醒我們，您的指導中是否有關於醫療補助重新確定的任何信息？您認為這個過程對 HCA 總體來說是積極還是消極？

Yes. Thanks for that. It's a good question. And you're right, it is still early, and we've got a pretty organized approach to not only continue to watch the market but respond to -- on there.

是的。感謝那。這是一個好問題。你是對的，現在還為時過早，我們有一個非常有組織的方法，不僅可以繼續觀察市場，還可以做出回應。

So we haven't seen any negative or any material impact on this today. We think what we're seeing many of the patients who are receiving determination, that -- there's some opportunity to continue to get them reenrolled in Medicaid, Some of them are more technical. They either didn't complete an application or some other aspect of that.

所以我們今天沒有看到任何負面或任何實質性影響。我們認為，我們看到許多正在接受決心的患者，有一些機會繼續讓他們重新加入醫療補助計劃，其中一些更具技術性。他們要么沒有完成申請，要么沒有完成申請的其他方面。

So our teams are trying to identify those individuals as best they can, assist them in gaining coverage, which remain encouraged by many of the studies that the people who are being redetermined off, who will qualify either for coverage in an employer sponsor plan or qualify for coverage in the health insurance marketplace. And so we'll continue to watch that as that unfolds. But no impact right now.

因此，我們的團隊正在盡力識別這些人，幫助他們獲得保險，許多研究仍然鼓勵這些人被重新確定，他們將有資格獲得雇主贊助計劃的保險或有資格覆蓋健康保險市場。因此，我們將繼續關注事態的發展。但目前沒有影響。

Nothing in our guidance is assumed for Medicaid redetermination. We believe over the long run, there could be some positive trends from this but we'll just have to wait to see how that plays out.

我們的指南中沒有任何內容是針對醫療補助重新確定的假設。我們相信，從長遠來看，這可能會帶來一些積極的趨勢，但我們只能拭目以待，看看結果如何。

And the next question comes from Kevin Fischbeck with Bank of America.

下一個問題來自美國銀行的 Kevin Fischbeck。

I wanted to just maybe dig in a little bit more to kind of how you're thinking about the volume growth in the back half of the year. I guess when you think about (inaudible) trending relatively similar in the back half versus the first half, I guess the way we had been thinking about it any way, it was that last year it felt like as COVID spiked at the beginning of the year and then became less and less of an issue that volumes started to kind of normalize in the back half of the year. And so that maybe the comp would be a little more difficult as you got into Q4 and if the growth rate might slow.

我想進一步深入了解一下您對今年下半年銷量增長的看法。我想當你想到後半段與前半段的（聽不清）趨勢相對相似時，我想我們一直在以任何方式思考這個問題，去年感覺就像新冠疫情在年初飆升一樣。今年下半年，銷量開始趨於正常化，問題變得越來越小。因此，當進入第四季度並且增長率可能放緩時，可能會變得更加困難。

So I just want to think about how you're thinking about volume growth and where you are versus maybe long-term trend lines and things like that. How do you put that into context about thinking this rate of growth will continue in the back half of the year?

因此，我只想考慮一下您如何看待銷量增長以及您與長期趨勢線之類的情況相比處於什麼位置。您如何看待這一增長速度將在今年下半年持續的情況？

Kevin, this is Sam. Let me give you sort of the backdrop, we think, of what exists for us with respect to volume. And this is more of a general commentary. I'll let Bill sort of reconcile the back half of the year to the first half of the year with numbers, I'm not sure I can do that at this particular point in time. As we said before, and we continue to believe this we feel that within our markets, there's unique attributes that are driving solid demand for health care services. Population growth continues to be strong in Texas and Florida, in Utah, Nevada, South Carolina, pretty much Tennessee. Across the board, we're experiencing population growth within our markets.

凱文，這是薩姆。我們認為，讓我向您介紹一下我們在數量方面存在的背景。這更多的是一般性評論。我會讓比爾用數字來協調下半年和上半年的情況，我不確定在這個特定的時間點我能做到這一點。正如我們之前所說，我們仍然相信這一點，我們認為在我們的市場中，有一些獨特的屬性正在推動對醫療保健服務的強勁需求。德克薩斯州和佛羅里達州、猶他州、內華達州、南卡羅來納州和田納西州的人口增長仍然強勁。總體而言，我們的市場內正在經歷人口增長。

The second point is we're investing very significantly in our strategy and our positioning within these communities so that we can respond to our patient needs, put our facilities in the best position to grow. And we think that's going to help us sustain market share growth as we move forward. What we're seeing is that our overall volume assumptions are supported by acuity. Acuity has maintained, some of that strategic, some of that, I think, is the dynamics that exist within the markets.

第二點是，我們對我們的戰略和在這些社區中的定位進行了大量投資，以便我們能夠滿足患者的需求，使我們的設施處於最佳的發展位置。我們認為這將幫助我們在前進的過程中維持市場份額的增長。我們看到的是，我們的總體交易量假設得到了敏銳度的支持。敏銳度一直保持著一些戰略性的態度，我認為其中一些是市場內存在的動態。

And then the second support mechanism that's in place, and we view this positively, is the payer mix dynamic. We have seen throughout the first half of the year, commercial admissions outpaced our total admissions. Again, we think that's reflective of a strong economy and job positioning that a lot of people have in our communities as well as the exchanges. And so we think those will continue on into the last half of this year. And we're optimistic that those will continue on into the future, at least in the near-term. So Bill, you can maybe try to reconcile...

然後，我們積極看待的第二個支持機制是付款人組合動態。我們看到整個上半年，商業招生超過了總招生。同樣，我們認為這反映了我們社區和交流中很多人擁有的強勁經濟和就業定位。因此，我們認為這些情況將持續到今年下半年。我們樂觀地認為，這些情況將持續到未來，至少在短期內。所以比爾，你也許可以嘗試和解......

I'll just say, I mean, when we think about projecting going forward, we try to take all of those factors into consideration, as Sam mentioned and where we're seeing year-to-date. Mind you, when we originally said our guidance, we anticipated 1% to 2% admission growth, mid-single-digit outpatient growth. So that's still hovering around 2% to 3% equivalent admission growth was our expectation.

我只想說，我的意思是，當我們考慮未來的規劃時，我們會嘗試考慮所有這些因素，正如薩姆提到的以及我們今年迄今為止所看到的那樣。請注意，當我們最初提出指導意見時，我們預計入院人數將增長 1% 至 2%，門診增長將達到中個位數。因此，我們的預期入場人數增長仍徘徊在 2% 至 3% 左右。

And given the fact that we're seeing north of 3% admission growth and 5.5% of adjusted admission, that's informing our position for the balance of the year. So I still think around 3 is a good number for the full year now based on the first 6 months of the year. We're continuing to see good outpatient revenue growth. And so that should support this 5% to 6% equivalent admission expectation for the full year.

考慮到我們看到的入學人數增長超過 3%，調整後的入學人數增長 5.5%，這表明我們對今年剩餘時間的立場。因此，根據今年前 6 個月的數據，我仍然認為 3 左右是全年的一個不錯的數字。我們繼續看到門診收入的良好增長。因此，這應該支持全年 5% 至 6% 的同等錄取預期。

Yes. And Bill, if I can add one thing. With respect to our investments in our networks. We have, at this particular juncture, the largest pipeline of projects that are in motion, including our outpatient development components which are very robust as well as other inpatient and facility needs there. So our pipeline from an organic standpoint as far as capital that we will see hit the market in latter '23, '24, early '25 is more robust than we've seen in pretty much recent years.

是的。比爾，如果我可以補充一件事。關於我們對網絡的投資。在這個特殊的時刻，我們擁有最大的正在進行中的項目，包括我們非常強大的門診開發組件以及其他住院和設施需求。因此，從有機的角度來看，我們將在 23 年末、24 年和 25 年初進入市場的資本比我們近幾年看到的更為強勁。

The next question comes from Brian Tanquilut with Jefferies.

下一個問題來自 Jefferies 的 Brian Tanquilut。

Bill, you touched on the impact of Envision being a 30 basis point drag. I know there's some -- a lot of noise happening with American Physician Partners and just stuff moving around the physician staffing. So as we think about that drag, is there opportunity to bring that up? Or is that like a more structural thing where you've had to bring in, in-house capabilities for physician staffing?

Bill，您談到了 Envision 拖累 30 個基點的影響。我知道有一些——美國醫師合作夥伴發生了很多噪音，而且只是在醫師人員配置方面發生了一些變化。因此，當我們考慮這種阻力時，是否有機會提出這個問題？或者這更像是一個更具結構性的事情，您必須為醫生人員配備引入內部能力？

Yes. This is Sam. Let me start with that and Bill can color in here. As I mentioned, the backdrop in the hospital-based physician space has been very difficult over the past few years because of multiple factors. And for us, in the short run, we have had to respond to these difficulties to maintain capacity and service availability and so forth. And so we did what we had to do to make sure that our business continue to move forward appropriately.

是的。這是薩姆。讓我從這個開始，比爾可以在這裡塗色。正如我所提到的，由於多種因素，過去幾年醫院醫生領域的背景非常困難。對於我們來說，從短期來看，我們必須應對這些困難，以維持容量和服務可用性等。因此，我們做了我們必須做的事情，以確保我們的業務繼續適當地向前發展。

And for the most part, we've overcome these pressures and been able to grow, and we've increased our earnings expectations for the year in the face of some of these challenges.

在很大程度上，我們已經克服了這些壓力並能夠實現增長，面對其中一些挑戰，我們提高了今年的盈利預期。

As Bill mentioned, we don't anticipate the same level of increases and pressures in the last half of the year, although we'll have some. But it's not going to nearly be what we've experienced in the first part, we don't think. And we do believe with the Valesco operations, we now have a platform that gives us the potential to respond better to these type of challenges and possibly integrate hospital-based physicians into our hospital operations even more effectively, producing better clinical performance efficiency and even growth, we think.

正如比爾提到的，我們預計今年下半年不會出現同樣水平的增長和壓力，儘管我們會有一些。但我們認為這不會是我們在第一部分中經歷的那樣。我們確實相信，通過 Valesco 業務，我們現在擁有一個平台，使我們有可能更好地應對此類挑戰，並可能更有效地將醫院醫生整合到我們的醫院運營中，從而產生更好的臨床表現效率甚至增長， 我們認為。

And so -- and I'll say this again, I said it earlier, we have a pattern of responding to different kind of operational challenges, whatever they happen to be. We've had labor, as I mentioned. We've had physician costs. Currently, we've had uninsured in the past. And we've tended to overcome them. In the short run, sometimes they can create an individual pressure. But I think the scale of HCA, the resources that we have and the ability to execute allows us to move through some of these pressures over time and get where we want to be.

因此，我要再說一遍，我之前說過，我們有一種應對不同類型運營挑戰的模式，無論它們是什麼。正如我提到的，我們已經分娩了。我們有醫生費用。目前，我們過去沒有保險。我們一直在努力克服它們。從短期來看，有時他們會造成個人壓力。但我認為 HCA 的規模、我們擁有的資源和執行能力使我們能夠隨著時間的推移克服其中一些壓力並達到我們想要的目標。

And the next question comes from Lance Wilkes with Bernstein.

下一個問題來自蘭斯·威爾克斯和伯恩斯坦。

I've got a strategic question for you on digital health and AI. I was just interested in the initiatives that you're kind of putting in place through the organization at this point, where you're maybe investing on the venture capital side here. And long term, what do you see is the opportunity for this, whether it's potentially reduced compensation or an ability to expand volume across the footprint?

我有一個關於數字健康和人工智能的戰略問題要問你。我只是對你們目前通過組織實施的舉措感興趣，你們可能在這裡投資風險投資。從長遠來看，您認為這方面的機會是什麼，無論是潛在的薪酬減少還是擴大覆蓋範圍的數量的能力？

This is Sam. We have a growing digital agenda in our company, and I'm very excited about what the prospects are for us around that. We are investing in a new clinical system, which we think is going to allow us to move information to the cloud more efficiently, and a matter of fact, move standard data sets into the cloud so that we can then use big data even more effectively and infuse that back into the care process.

這是薩姆。我們公司的數字議程不斷發展，我對我們的前景感到非常興奮。我們正在投資一個新的臨床系統，我們認為這將使我們能夠更有效地將信息轉移到雲端，事實上，將標準數據集轉移到雲端，以便我們可以更有效地使用大數據並將其註入護理過程中。

We will couple our digital agenda with something we're calling care transformation & innovation. And inside of that, we believe we have opportunities to improve care processes, eliminate a lot of the variation that exists today in our company, creating better quality and, at the same time, more efficiencies.

我們將把我們的數字議程與我們所說的護理轉型和創新結合起來。其中，我們相信我們有機會改進護理流程，消除我們公司目前存在的許多差異，創造更好的質量，同時提高效率。

Artificial intelligence, we believe, will play a huge part in that. It's way early for us to know exactly what that will be and how that will influence our agenda, but we're encouraged about the prospects for it. We are partnering with some very sophisticated companies to help us push through this in ways that I think will accelerate our agenda and inform it with more expertise than what we have internally. So we're excited about what this can yield for us as we push into our next life cycle, if you will. And we'll wait to see what artificial intelligence, in fact, can do. But we view it as a positive potential for us in a very significant way.

我們相信，人工智能將在其中發揮重要作用。對於我們來說，確切地知道這將是什麼以及這將如何影響我們的議程還為時過早，但我們對其前景感到鼓舞。我們正在與一些非常成熟的公司合作，幫助我們推動這一進程，我認為這將加速我們的議程，並提供比我們內部更多的專業知識。因此，如果您願意的話，當我們進入下一個生命週期時，我們對這能為我們帶來什麼感到興奮。我們將拭目以待，看看人工智能實際上能做什麼。但我們認為它對我們來說具有非常重要的積極潛力。

The next question comes from Andrew Mok with UBS.

下一個問題來自瑞銀集團的安德魯·莫克（Andrew Mok）。

I just wanted to follow up on the pricing discussion maybe from a different angle. Revenue per outpatient equivalent looks, like it was down about 1% in the quarter, which seems to be weighing on strong inpatient pricing up 6%. Can you help us understand the pricing and mix trends across your outpatient platform that are causing that unit revenue metric to blend down this year?

我只是想從不同的角度跟進定價討論。本季度每名門診患者的收入看起來下降了約 1%，這似乎對強勁的住院價格上漲 6% 造成了壓力。您能否幫助我們了解導致今年單位收入指標下降的整個門診平台的定價和組合趨勢？

Well, I'd say we're pleased with the outpatient growth that we're seeing. If you look at the overall outpatient growth that we have, it's -- our expectation was mid-single digits. We're well north of that in the quarter and on a year-to-date basis. There's always a little bit of a mix issue that occurs. Our emergency room volume was up, what, 3.7%, which [were] a lot of are outpatient. Our outpatient surgical growth was up 3.3% in the quarter. So I think those are really good stats. On the outpatient revenue, per unit. There's always a blend between surgical, emergency room and diagnostic. But I would say, overall, we're very pleased with the outpatient overall growth that we are seeing.

嗯，我想說，我們對所看到的門診增長感到滿意。如果你看看我們的整體門診增長，我們的預期是中個位數。從本季度和年初至今來看，我們都遠遠超出了這一水平。總是會出現一些混合問題。我們的急診室數量增加了 3.7%，其中很多是門診患者。本季度我們的門診手術量增長了 3.3%。所以我認為這些都是非常好的統計數據。每單位門診收入。手術室、急診室和診斷室總是混合在一起的。但我想說，總的來說，我們對所看到的門診整體增長感到非常滿意。

Yes. And Bill, just the second quarter overall outpatient revenue growth was actually up over the first quarter. So we are seeing some acceleration. There's a lot of moving parts, as Bill just alluded to, to outpatient revenues between physician, clinics, urgent care, all the way up to outpatient cardiology procedures, which tend to be our highest reimbursed type of procedures. And so the mix of that can influence the outpatient. We tend to look at it in the aggregate. And for the most part, our aggregate revenue growth has been stronger in the second quarter than it was in the first quarter.

是的。比爾表示，僅第二季度整體門診收入增長實際上就比第一季度有所上升。所以我們看到了一些加速。正如比爾剛才提到的，醫生、診所、緊急護理、一直到門診心髒病手術之間的門診收入有很多變化，這往往是我們報銷最高的手術類型。因此，這些因素的結合會影響門診病人。我們傾向於從總體上看待它。在很大程度上，我們第二季度的總收入增長比第一季度強勁。

And then within sort of the pricing elements, we continue to get the targeted price increases that we want in both our inpatient and our outpatient businesses. So it's more, to Bill's point, sort of the mix and the mixture of all of the different components in a way that has produced solid growth for us.

然後，在定價要素的範圍內，我們繼續在住院和門診業務中實現我們希望的目標價格上漲。因此，在比爾看來，更多的是所有不同成分的混合和混合，從而為我們帶來了穩健的增長。

Next question comes from Calvin Sternick with JPMorgan.

下一個問題來自摩根大通的卡爾文·斯特尼克。

I wanted to ask about the commercial rate cycle. I think last quarter, you said you guys are about 2/3 of the way through 2024 and about 1/4 of the way through 2025. Can you give us an update on the progress and how those rate discussions are evolving?

我想問一下商業利率週期。我想上個季度，你們說過 2024 年已經過去了 2/3，2025 年也已經過去了 1/4。您能給我們介紹一下最新進展情況以及這些利率討論的進展情況嗎？

Yes. They're evolving pretty consistent. As we just mentioned, we're continuing to see rates in kind of the mid-single digit level. As far as contracted for '24, I think we're a little north of 70% for '24 now. And I think our efforts continue. I think our relationships with our major payers continue to be strong and we're pleased with the progress we're making in that area.

是的。它們的發展非常一致。正如我們剛才提到的，我們繼續看到利率處於中個位數水平。就 24 年的合同而言，我認為我們現在已經略高於 24 年的 70%。我認為我們的努力仍在繼續。我認為我們與主要付款人的關係仍然牢固，我們對我們在該領域取得的進展感到滿意。

And the next question comes from Scott Fidel with Stephens.

下一個問題來自斯科特·菲德爾和斯蒂芬斯。

Interested just as against the backdrop where the managed care payers are seeing the higher medical cost trends this year, whether you're seeing any changes in behaviors when interfacing with them from a prior authorization or utilization management-type perspective? Or are things pretty consistent there?

在管理式醫療支付者今年醫療費用呈上升趨勢的背景下，您是否感興趣，從事先授權或利用管理類型的角度與他們互動時，您是否看到了行為上的任何變化？或者那裡的情況非常一致？

And then just a quick follow-up, just on the slight raise in the CapEx. Is that just related to the general broad-based investments that Sam just talked about? Or are there any specific projects that you would cite around the update to the CapEx guide?

然後是快速跟進，只是資本支出略有增加。這是否與 Sam 剛才談到的一般廣泛投資有關？或者您是否會在資本支出指南的更新中引用任何具體項目？

Yes, Let me try to take both of those. I think as we maybe mentioned in the past, as you think about authorization and medical necessity reviews, those activities have picked up again as -- during the COVID period of time, those have eased a little bit. But we still see a lot of friction, if you will, as you go through that effort. We work with our payers to try to resolve those appropriately, make sure that we defend our positions where necessary. But there is a level of activity that both us and the payers have to devote to try to smooth through that process. But we tend to be able to work our way through it.

是的，讓我嘗試兩者兼得。我認為，正如我們過去可能提到的那樣，當你考慮授權和醫療必要性審查時，這些活動再次增加，因為在新冠疫情期間，這些活動有所緩解。但如果你願意的話，當你經歷這些努力時，我們仍然會看到很多摩擦。我們與付款人合作，努力妥善解決這些問題，確保我們在必要時捍衛我們的立場。但我們和付款人都必須投入一定程度的活動來努力順利完成這一過程。但我們往往能夠通過自己的努力度過難關。

On the CapEx, I think it's simply reflective of the oportunities we see in the market to continue to deploy capital for growth. Fortunately, we continue to see really strong cash flow to be able to support that CapEx. And again, I think it's reflective of the growth opportunities we see in the market.

在資本支出方面，我認為這只是反映了我們在市場上看到的繼續部署資本以促進增長的機會。幸運的是，我們繼續看到非常強勁的現金流能夠支持資本支出。再說一次，我認為這反映了我們在市場上看到的增長機會。

And Bill, as we mentioned on the last call, we have acquired some land for future expansion in some of these fast-growing markets that we serve, and that's put some upward pressure on our capital spending. But we believe those are long-term good decisions for us.

比爾，正如我們在上次電話會議中提到的，我們已經購買了一些土地，用於未來在我們服務的一些快速增長的市場中進行擴張，這給我們的資本支出帶來了一些上行壓力。但我們相信這些對我們來說是長期的良好決定。

The next question comes from Jason Cassorla with Citi Group.

下一個問題來自花旗集團的 Jason Cassorla。

Yes. Great. Just wanted to ask a little bit more on the labor front. Thinking about all the efforts and programs you put in place contributing to the better turnover in hiring trends, I guess, is there a way to help frame what inning you're in as it relates to these efforts? Where do you like to see some of the outputs on turnover retention kind of move to? Or any other thoughts on the labor front and the trajectories there?

是的。偉大的。只是想多問一些關於勞工方面的問題。考慮到您為提高招聘趨勢而做出的所有努力和計劃，我想，有沒有一種方法可以幫助您確定與這些努力相關的階段？您希望看到有關營業額保留的一些成果轉移到哪裡？或者對勞工戰線和那裡的軌跡還有其他想法嗎？

Yes. This is Sam. Thank you for that question. As I mentioned, we have invested very heavily in our people agenda over the past few years. We've increased our capacity within our recruiting function. Our recruiting efforts are yielding strong hiring, and we believe that will continue on into the latter half of the year.

是的。這是薩姆。謝謝你提出這個問題。正如我所提到的，過去幾年我們在人才議程上投入了大量資金。我們增強了招聘職能的能力。我們的招聘工作正在產生強勁的招聘效果，我們相信這種情況將持續到今年下半年。

Our retention efforts with respect to responding to our employees' needs so that they have the necessary resources and tools to be effective in their day-to-day jobs, we're getting better at that. That's helping turnover. Turnover is approaching pre-pandemic levels, especially in the nursing area. We are a few points above pre-pandemic. But if you annualize the second quarter turnover, it would suggest less than that. So we're encouraged by that, and we do believe we have opportunities to continue improvement in that area. With contract labor, as Bill mentioned, we expect to see improvements as we move through the last half of the year.

我們在留住員工方面所做的努力是為了滿足員工的需求，以便他們擁有必要的資源和工具來有效地完成日常工作，我們在這方面做得越來越好。這有助於營業額。營業額已接近大流行前的水平，尤其是在護理領域。我們比大流行前的情況要好一些。但如果你將第二季度的營業額按年化計算，結果會低於這個數字。因此，我們對此感到鼓舞，並且我們確實相信我們有機會在該領域繼續改進。正如比爾提到的，對於合同工，我們預計在今年下半年會有所改善。

And then I'm very excited about our workforce development initiatives. We continue to invest heavily in Galen College of Nursing. They're expanding each quarter, it seems, into new markets and establishing new relationships and new opportunities for people and for our company. And then we're also investing in our -- what we're calling our Centers for Clinical Advancement, which is our ongoing clinical education for our people so that they can upskill their capabilities and competencies and put them in a position to either deliver better care or grow in their own individual career.

我對我們的勞動力發展計劃感到非常興奮。我們繼續對蓋倫護理學院進行大量投資。他們似乎每個季度都在拓展新市場，為人們和我們公司建立新的關係和新的機會。然後，我們還投資於我們所謂的臨床進步中心，這是我們為員工提供持續的臨床教育，以便他們能夠提高自己的能力和能力，並使他們能夠提供更好的服務關心或發展自己的個人職業生涯。

So what inning are we in? We're in the middle innings in some of the areas. And so we will wait to see how the latter half of the year plays out. But all in all, I think tremendous results. We're very competitive, we believe, across the organization with our compensation and benefit programs. And as I mentioned earlier, we've been able to navigate through these difficult periods and maintain margins. I think our labor costs -- again, if you just look at 2019 as a proxy, our labor cost in 2023 are below as a percent of revenue 2019. And again, that's in the very -- in the face of a very difficult labor market.

那麼我們現在處於第幾局呢？我們在某些​​地區正處於中局。因此，我們將拭​​目以待，看看下半年的情況如何。但總而言之，我認為成果巨大。我們相信，我們的薪酬和福利計劃在整個組織中都非常有競爭力。正如我之前提到的，我們已經能夠度過這些困難時期並保持利潤。我認為我們的勞動力成本 - 再說一次，如果你只看 2019 年作為代理，我們 2023 年的勞動力成本低於 2019 年收入的百分比。而且，這也是在非常困難的勞動力面前市場。

The next question comes from Jamie Perse with Goldman Sachs.

下一個問題來自高盛的 Jamie Perse。

Can you comment on seasonality expectations for the third quarter? Anything beyond normal seasonality from a headwind or tailwind perspective that we should be thinking about? And I think normally, revenue is down slightly and EBITDA down maybe mid-single digits to high single digits. Is that the right way to be thinking about the third quarter? And anything in July that's informing that?

您能否評論一下第三季度的季節性預期？從逆風或順風的角度來看，有什麼超出正常季節性的因素是我們應該考慮的嗎？我認為通常情況下，收入會略有下降，EBITDA 可能會下降中個位數到高個位數。這是思考第三季度的正確方式嗎？七月有什麼消息可以說明這一點嗎？

And then there was an earlier question on backlog that may not have been fully answered. I'd love to hear your thoughts on that as well.

還有一個關於積壓的較早問題可能尚未得到完全解答。我也很想听聽您對此的想法。

We mentioned at the end of the fourth quarter that we were starting to see normal seasonality patterns materialize. And we've seen that so far through the first half of this year, and we think that will continue on into the second half of this year. The third quarter is not as strong as the fourth quarter. The fourth quarter is always the strongest quarter of the year for us given the outpatient activity and deductibles and so forth. And so we think the third and fourth quarter will be similar in patterns to pre-pandemic seasonality. And that's what's reflected in our guidance.

我們在第四季度末提到，我們開始看到正常的季節性模式成為現實。到目前為止，我們已經看到了今年上半年的情況，我們認為這種情況將持續到今年下半年。第三季度的表現不如第四季度。考慮到門診活動和免賠額等因素，第四季度始終是我們一年中最強勁的季度。因此，我們認為第三季度和第四季度的模式將與大流行前的季節性相似。這就是我們的指導中所反映的內容。

And the next question will come from Steven Valiquette.

下一個問題將由 Steven Valiquette 提出。

So I guess as a follow-up to just some of these prior questions on the labor and commercial rate update. There was some conjecture for HCA that the company didn't have quite as many commercial payer contracts up for renewal for fiscal '23 to capture some better rates for elevated labor costs, which you had more coming up for renewal in '24.

因此，我想這是對之前有關勞動力和商業利率更新的一些問題的後續行動。 HCA 推測，該公司在 23 財年沒有那麼多商業付款人合同需要續簽，無法為勞動力成本上升獲得更好的利率，而在 24 財年會有更多合同需要續簽。

Now that the noise levels kind of died down somewhat here in mid-23 on overall labor cost pressure versus -- something versus 12, 15 months ago, I guess the question is do you still have confidence to potentially capture potentially slightly better than average commercial rate updates for fiscal '24? Is labor pressure maybe still being the key variable within those discussions? Or are those going to be a little bit tougher now given that some of the pressure is subsided. Just want to get your kind of latest thoughts around that.

現在，與 12、15 個月前相比，由於整體勞動力成本壓力，噪音水平在 23 月中旬有所減弱，我想問題是，您是否仍然有信心潛在地捕捉到比平均水平稍好的商業廣告24 財年利率更新？勞動力壓力可能仍然是這些討論中的關鍵變量嗎？或者考慮到一些壓力已經消退，這些現在會變得更加艱難嗎？只是想了解您對此的最新想法。

Well, this is Sam. Bill indicated that we're 70% contracted on '24 around our targeted escalation objective. Labor costs, as you mentioned, are moderating some. Yes, there's still inflationary pressures underneath it, as one would expect. Now we have physician cost pressures with respect to pro fees. And our belief is that, that will have to be paid for by someone. And so that will become a new factor in our thinking and our justification for appropriate price increases. So our cost -- we're not just one category. We have multiple categories, as you can see on the income statement. And all of that factors into our considerations when we're negotiating.

嗯，這是薩姆。 Bill 表示，我們在 24 年完成了 70% 的合同，圍繞我們的升級目標。正如您提到的，勞動力成本正在下降。是的，正如人們所預料的那樣，其背後仍然存在通脹壓力。現在我們面臨著醫生在專業費用方面的成本壓力。我們相信，這必須由某人付出代價。因此，這將成為我們思考和合理提價的新因素。所以我們的成本——我們不僅僅是一類。正如您在損益表中看到的那樣，我們有多個類別。所有這些因素都會成為我們談判時考慮的因素。

And the next question will come from Joshua Raskin with Nephron Research.

下一個問題將由 Nephron Research 的 Joshua Raskin 提出。

Were there any meaningful differences in the payer mix on the outpatient side, an obvious focus on Medicare and specifically Medicare Advantage volumes. And are you seeing anything in the Medicare market that would support higher levels of demand than we saw last quarter or the quarter before, anything that you feel like is inflecting?

門診方面的付款人組合是否存在任何有意義的差異，明顯關注醫療保險，特別是醫療保險優勢金額。您是否在醫療保​​險市場中看到任何可以支持比上季度或前一季度更高的需求水平的東西，您認為有什麼東西正在發生變化嗎？

Yes, Josh, when I look at kind of the admissions versus adjusted admissions between the payer categories, they're comparable. Our Medicare adjusted admissions were up 5%. Our managed care adjusted admissions were up 5%, as we mentioned earlier, fueled by emergency room growth. So I think the trends are pretty comparable among the payer categories. And that's strengthening payer mix, that's, I think, positive trends for us. So nothing else underneath the outpatient area that I would distinguish, other than we continue to see good commercial ER traffic. Our commercial outpatient was up pushing close to 4% as well. So again, I think they're pretty comparable in terms of the general trends we're seeing.

是的，喬什，當我查看付款人類別之間的入學人數與調整後的入學人數時，它們是具有可比性的。我們的 Medicare 調整後入院人數增加了 5%。正如我們之前提到的，在急診室增長的推動下，我們的管理式醫療調整後入院人數增長了 5%。所以我認為付款人類別之間的趨勢相當可比。這正在加強付款人組合，我認為這對我們來說是積極的趨勢。因此，除了我們繼續看到良好的商業急診流量外，門診區域下面沒有其他我可以區分的東西。我們的商業門診量也增長了近 4%。再說一遍，我認為就我們所看到的總體趨勢而言，它們非常具有可比性。

I would say, Bill, just to put a little bit of color on the outpatient. Our commercial outpatient revenue growth is clearly outpacing our Medicare outpatient revenue growth. Some of the adjusted admissions are influenced by some of the calculations, if you will. But we are seeing really solid commercial outpatient revenue growth, again, influenced by the ER, influenced by surgeries, which are represented by roughly 50% to 55% commercial. So good growth there. And all of that yields solid commercial revenue growth.

我想說，比爾，只是為了給門診增添一點色彩。我們的商業門診收入增長明顯超過了醫療保險門診收入增長。如果您願意的話，一些調整後的招生會受到某些計算的影響。但我們看到商業門診收入增長非常穩健，這再次受到急診室和手術的影響，其中商業門診佔大約 50% 至 55%。那裡的成長非常好。所有這些都帶來了穩健的商業收入增長。

There are no further questions. At this time. Mr. Frank Morgan, I turn the call back over to you.

沒有其他問題了。此時。弗蘭克·摩根先生，我將電話轉回給您。

Bailey, thank you so much for your help today. Thanks, everyone, for joining our call. I hope you have a wonderful rest of your week. And I'm around this afternoon if we can answer any additional questions you might have. Thank you very much. Have a great day.

貝利，非常感謝你今天的幫助。謝謝大家加入我們的電話會議。我希望您這一周過得愉快。如果我們可以回答您可能有的任何其他問題，我今天下午就會來。非常感謝。祝你有美好的一天。

This concludes today's conference call. You may now disconnect.

今天的電話會議到此結束。您現在可以斷開連接。