美國醫院公司 (HCA) 2023 Q4 法說會逐字稿

Welcome to the HCA Healthcare Fourth Quarter 2023 Earnings Conference Call. Today's call is being recorded. (Operator Instructions). 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 年第四季財報電話會議。今天的通話正在錄音。 （操作員說明）。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. Before I turn the call over to Sam, let me remind everyone that should today's call contain any forward-looking statements that 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.

早安，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執行長 Sam Hazen；和財務長比爾盧瑟福。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。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應該包含任何基於管理層當前預期的前瞻性陳述。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有重大差異。有關前瞻性陳述和這些因素的更多資​​訊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 Healthcare Inc. is included in today's 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。今天的發布中包含了一份表格，提供了調整後 EBITDA 和調節歸屬於 HCA Healthcare Inc. 淨利潤的補充資訊。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。

All right. Good morning to everybody and thank you for joining the call. We finished 2023 better than expected across most dimensions of our business. In the quarter, we experienced strong demand for services across our diversified portfolio of markets, facilities and service lines. This growth coupled with improved cost trends drove solid financial performance in the fourth quarter.

好的。大家早安，感謝您加入通話。 2023 年，我們業務的大部分方面都優於預期。本季度，我們多元化的市場、設施和服務線組合中的服務需求強勁。這種成長加上成本趨勢的改善推動了第四季度穩健的財務表現。

Diluted earnings per share excluding gains on sales were $5.90, which represented a 27% increase over prior year. We are encouraged by these results and believe the operational momentum we have created should position us well for 2024.

扣除銷售收益後的稀釋每股收益為 5.90 美元，比上年增長 27%。我們對這些結果感到鼓舞，並相信我們創造的營運動能將為我們在 2024 年做好準備。

As mentioned at our recent Investor Day, the staying power of HCA Healthcare was on display again throughout the year. Diluted earnings per share, excluding gains and losses on sales and debt retirement for the year grew almost 13% as compared to 2022. As a management team, we pride ourselves on the following: first, owning our realities, whatever they are. Next, making a big company small so we can adjust timely; and third, being disciplined in thought, resource allocation and execution, helping us to accomplish our mission.

正如我們在最近的投資者日所提到的，HCA Healthcare 的持久力在這一年中再次展現出來。與2022 年相比，今年的稀釋每股收益（不包括銷售損益和債務清償）增長了近13%。作為管理團隊，我們為以下幾點感到自豪：首先，承認我們的現實，無論它們是什麼。其次，把大公司做小，以便及時調整；第三，在思想、資源配置和執行上保持紀律，幫助我們完成我們的使命。

Once again, I believe our people have impressively demonstrated these traits in the face of new challenges and delivered positive outcomes for our patients, the communities we serve and our other stakeholders. Often refer to them as can do people and again, this past year, I think they proved it. I want to thank them for their hard work and everything they do for our company.

我相信我們的員工在面對新挑戰時再次出色地展示了這些特質，並為我們的患者、我們服務的社區和其他利益相關者帶來了積極的成果。經常稱他們為能做事的人，在過去的一年裡，我認為他們再次證明了這一點。我要感謝他們的辛勤工作以及他們為我們公司所做的一切。

Same-facility volumes across the company were strong in the fourth quarter. Admissions grew 3% year-over-year. Equivalent admissions were up 4%, emergency room visits grew 2%, inpatient and outpatient surgery volumes increased approximately 1%. Most of our other volume categories including cardiac procedures and rehab admissions had solid growth metrics in the quarter also.

第四季整個公司同設施的銷售強勁。招生人數較去年同期成長 3%。同等入院人數增加了 4%，急診人數增加了 2%，住院和門診手術量增加了約 1%。我們的大多數其他數量類別（包括心臟手術和復健入院）在本季也有穩健的成長指標。

All domestic divisions had equivalent admissions growth in the quarter. Additionally, payer mix and acuity levels in the quarter improved year-over-year. These factors along with certain enhancements in a couple of states Medicaid supplemental programs helped produce same facilities revenue growth of 11% in the quarter. Bill will provide more detail on revenue in his comments.

本季所有國內部門的招生人數都有相同的成長。此外，本季的付款人組合和敏銳度水準較去年同期有所改善。這些因素加上幾個州醫療補助補充計劃的某些增強，幫助該季度相同設施的收入增長了 11%。比爾將在評論中提供有關收入的更多詳細資訊。

Operating margins improved in the quarter as we were able to generate solid operating leverage across the company on the increased revenue we produced as compared to the prior year. But even more impressively when compared sequentially to the third quarter, we executed well over the year on our people agenda. In the quarter, we saw further progress on key metrics as evidenced by solid employee engagement results, stable turnover trends and reductions in contract labor utilization.

本季營業利潤率有所提高，因為我們能夠利用與前一年相比增加的收入在整個公司範圍內產生穩固的營業槓桿。但更令人印象深刻的是，與第三季相比，我們全年在人員議程上的執行情況良好。本季度，我們在關鍵指標上取得了進一步進展，堅實的員工敬業度、穩定的營業額趨勢和合約工利用率的減少就證明了這一點。

As we have detailed in the past, we have implemented a comprehensive human resources plan. We expect to make further progress on it as we move into 2024. Our plan will remain a top organizational priority with significant investments in workforce development and training, which includes expansions in both Galen College of Nursing and our centers for clinical advancement.

正如我們過去詳細介紹的那樣，我們實施了全面的人力資源計劃。進入 2024 年，我們預計將在這方面取得進一步進展。我們的計劃仍將是組織的首要任務，對勞動力發展和培訓進行大量投資，其中包括蓋倫護理學院和臨床進步中心的擴建。

With respect to hospital-based physician costs in the quarter, we slowed the rate of growth. As it pertains to Valesco, our physician staffing joint venture, we reduced the operating loss in the fourth quarter, more in line with our expectations. As indicated at our Investor Day, we expect to invest significantly this year in our long-term plans, which we designed to take our company from strength to strength and achieve the growth potential we see in our core business.

就本季醫院醫生費用而言，我們放緩了成長速度。由於與我們的醫生人員合資企業 Valesco 有關，我們減少了第四季度的營運虧損，更符合我們的預期。正如我們在投資者日所表明的那樣，我們預計今年將在我們的長期計劃中進行大量投資，我們旨在使我們的公司不斷壯大，並實現我們在核心業務中看到的成長潛力。

These investments revolve around 3 distinct opportunities. The first one includes continued network expansion in facilities, services and workforce to meet the demand growth that we expect in our markets while also supporting our efforts to increase market share. In 2024, we have over $2 billion of new capital projects scheduled to come online that will increase capacity. Additionally, we expect to integrate a number of newly acquired hospitals and outpatient facilities that should complement our networks.

這些投資圍繞著 3 個不同的機會。第一個包括持續擴大設施、服務和勞動力網絡，以滿足我們預期的市場需求成長，同時支持我們增加市場份額的努力。到 2024 年，我們將有超過 20 億美元的新資本項目計劃上線，以增加產能。此外，我們希望整合一些新收購的醫院和門診設施，以補充我們的網路。

The second opportunity includes a robust agenda designed to advance digital capabilities across the company and unlock the embedded value we see in our operations. As high performing as we are today, we believe there is more operational potential inside our company. With evolving technological tools, we are investing to unlock this value. We believe this initiative, together with our care transformation and innovation program will enhance quality, drive further efficiencies through our financial resiliency program and improve overall operational management capabilities, including integrating our revenue cycle and case management functions better.

第二個機會包括一個強大的議程，旨在提升整個公司的數位能力並釋放我們在營運中看到的內在價值。儘管我們今天表現出色，但我們相信公司內部還有更大的營運潛力。隨著科技工具的不斷發展，我們正在投資來釋放這一價值。我們相信，這項措施與我們的護理轉型和創新計劃一起將提高質量，透過我們的財務彈性計劃進一步提高效率，並提高整體營運管理能力，包括更好地整合我們的收入週期和案例管理職能。

The third area of opportunity pertains to the flexibility we have to use our balance sheet position and strong cash flow production to invest heavily in our business and our people while also allocating capital to our shareholders. In 2024, we plan to increase capital spending to over $5 billion and enhance our share repurchase program to around $5 billion. We continue to believe this strategic plan will produce more winning play for our organization, allowing us to deliver better services for patients while also creating value for other stakeholders.

第三個機會領域涉及我們必須靈活地利用我們的資產負債表狀況和強勁的現金流量來大力投資我們的業務和員工，同時也向我們的股東分配資本。到 2024 年，我們計劃將資本支出增加到 50 億美元以上，並將股票回購計畫增加到 50 億美元左右。我們仍然相信，這項策略計畫將為我們的組織帶來更多的勝利，使我們能夠為患者提供更好的服務，同時也為其他利害關係人創造價值。

Let me close with this, the constituency in our organization consists of 3 principles: giving our patients what they deserve whenever they need services, partnering with our physicians to deliver high-quality outcomes and leveraging the distinct elements of HCA Healthcare to improve performance. Our approach to delivering on these core values comes from what we term the HCA way. That is supporting our local provider systems with value-added enterprise-level capabilities coupled with disciplined and detailed oriented management teams that relentlessly focus on execution. This operating philosophy has helped us navigate different economic cycles, adapt to changes in the industry and address challenges such as the COVID pandemic.

最後，我想說的是，我們組織的支持者由3 項原則組成：在患者需要服務時為他們提供應得的服務，與我們的醫生合作提供高品質的結果，並利用HCA Healthcare 的獨特元素來提高績效。我們實現這些核心價值的方法來自我們所謂的 HCA 方式。這就是透過增值的企業級能力以及堅持不懈地專注於執行的紀律嚴明、注重細節的管理團隊來支持我們的本地提供者係統。這種經營理念幫助我們駕馭不同的經濟週期，適應產業變化，並應對新冠疫情等挑戰。

As we look to the future, we have designed our next-generation growth plan to build upon the strengths we have developed over the years and take advantage of the opportunities in front of us. I am proud of HCA Healthcare. I'm even more proud of our people. We will move into 2024 in the years ahead with greater purpose with a renewed agenda to drive sustained growth and with a confidence in our ability to deliver value and positive outcomes for our stakeholders. With that, I'll turn the call to Bill and he will discuss in more detail the quarter's results and 2024 guidance.

展望未來，我們設計了下一代成長計劃，以鞏固我們多年來發展的優勢，並利用擺在我們面前的機會。我為 HCA 醫療保健感到自豪。我為我們的人民感到更加自豪。未來幾年，我們將帶著更大的目標、新的議程來推動持續成長，並對我們為利害關係人創造價值和積極成果的能力充滿信心，邁入 2024 年。接下來，我會將電話轉給 Bill，他將更詳細地討論本季的業績和 2024 年的指導。

Okay. Great. Thank you, Sam, and good morning, everyone. I will provide some additional comments on our performance for the quarter and year and then discuss our 2024 guidance.

好的。偉大的。謝謝你，山姆，大家早安。我將對我們本季和年度的業績提供一些額外的評論，然後討論我們的 2024 年指導。

We highlighted at our recent Investor Day that our formula of combining strong operational performance with a disciplined and balanced allocation of capital has a long track record of generating value over time. Our results for 2023 and our guidance for 2024 reflect a continuation of this formula. Sam provided many of our fourth quarter indicators in his comments. So let me take a moment to review some of our results for the full year 2023.

我們在最近的投資者日強調，我們將強勁的營運績效與嚴格、平衡的資本配置相結合的公式長期以來一直在創造價值。我們 2023 年的結果和 2024 年的指導反映了這個公式的延續。 Sam 在他的評論中提供了我們第四季度的許多指標。讓我花點時間回顧一下 2023 年全年的一些結果。

We have strong top line growth. For the year, our same facility admissions grew 3.3% over prior year. Equivalent admissions grew 4.8%. Emergency room business grew 4.7% and total surgical cases were up 2.3%. We maintained our strong acuity trends with case mix index increasing and payer mix improved with managed care and other admissions growing 6% for the full year on a same-facility basis. Revenue per equivalent admission grew 2.7% on a same facility basis. This contributed to same-facility revenue growing 7.6% and 7.9% on a consolidated basis for the full year 2023.

我們的營收成長強勁。今年，我們同一設施的入院人數比前一年增加了 3.3%。同等入學人數增加了 4.8%。急診室業務成長 4.7%，手術病例總數成長 2.3%。我們保持了強勁的敏銳度趨勢，病例組合指數不斷增加，付款人組合也得到改善，管理式醫療和其他入院人數在同一設施的基礎上全年增長了 6%。在相同設施的基礎上，每場同等入場費的收入增加了 2.7%。這使得 2023 年全年的同設施收入綜合成長 7.6% 和 7.9%。

We couple top line strength with strong management of operating costs. Salaries, wages and benefits as a percentage of revenue improved 60 basis points on a consolidated basis compared to prior year. Contract labor declined 20% for the year and equated to 5.3% of SWB in the fourth quarter. Our teams continue to do a great job managing the supply costs, which improved 40 basis points as a percentage of revenue for the full year.

我們將營收實力與強而有力的營運成本管理結合。與前一年相比，薪資、薪資和福利佔收入的百分比在綜合基礎上提高了 60 個基點。合約工全年下降 20%，相當於第四季度 SWB 的 5.3%。我們的團隊繼續出色地管理供應成本，佔全年收入的百分比提高了 40 個基點。

As we have mentioned throughout the year, we are managing through pressures on professional fees and hospital-based physician costs. But we saw an improvement in the sequential rate of growth in both the third and fourth quarter. Sam mentioned, we also saw an improvement in our Valesco joint venture, which was in line with our expectations. We are confident in our plans to continue working through what we believe are industry-wide pressures in this area.

正如我們全年所提到的，我們正在應對專業費用和醫院醫生費用的壓力。但我們看到第三季和第四季的環比成長率有所改善。 Sam提到，我們也看到了Valesco合資企業的改善，這符合我們的預期。我們對繼續努力克服該領域全行業壓力的計劃充滿信心。

The result of this is we produced solid margins of 19.6% in line with our range of expectations on a consolidated basis and adjusted EBITDA growth of 5.5% on an as-reported basis for the full year 2023. So as a management team, we are very pleased with the operational performance of the company during the year.

結果是，我們的綜合利潤率為 19.6%，符合我們的預期，2023 年全年調整後 EBITDA 增長為 5.5%。因此，作為管理團隊，我們對該公司一年來的經營業績非常滿意。

Let me briefly discuss our results in the fourth quarter. Adjusted EBITDA grew just under 14% in the quarter as compared to the prior year. This is primarily due to strong revenue growth and solid expense management during the quarter. In addition to our strong core business trends, we recognized a year-over-year adjusted EBITDA increase of approximately $250 million related to our supplemental payment programs. This includes the new North Carolina program and certain favorable adjustments within the Texas program.

讓我簡要討論一下我們第四季的業績。本季調整後 EBITDA 與上年同期相比成長略低於 14%。這主要是由於本季強勁的收入成長和穩健的費用管理。除了我們強勁的核心業務趨勢之外，我們還發現與我們的補充付款計劃相關的調整後 EBITDA 同比增長了約 2.5 億美元。這包括新的北卡羅來納州計劃和德克薩斯州計劃內的某些有利調整。

Additionally, based on our experience with the program to date, we began accruing the Florida program in the quarter whereas previously, we had recognized this program on an annual lump sum basis. Our recently acquired entities as well as facilities divested in the prior year resulted in about $90 million less adjusted EBITDA in the quarter, with roughly half of this decline from the Valesco joint venture.

此外，根據我們迄今為止對該計劃的經驗，我們在本季度開始累積佛羅裡達州計劃，而此前，我們是按年度一次性付款方式確認該計劃的。我們最近收購的實體以及上一年剝離的設施導致本季調整後 EBITDA 減少約 9,000 萬美元，其中約一半的下降來自 Valesco 合資企業。

In summary, the quarter was the strongest operational performance of the year. And with the additional benefit from the supplemental programs and impact of new and divested facilities, we are very pleased with the year-over-year growth we were able to produce.

總而言之，該季度是今年最強勁的營運業績。憑藉補充計劃的額外好處以及新設施和剝離設施的影響，我們對我們能夠實現的同比增長感到非常滿意。

So next, let me speak to capital allocation. We deployed a balanced allocation of capital in 2023. For the full year, our cash flow from operations was $9.4 billion compared to $8.5 billion in the prior year or just under 11% growth. Capital expenditures were just above $4.7 billion for the year, which was in line with our expectations. We purchased approximately $3.8 billion of our outstanding shares and paid approximately $660 million of dividends during the year.

接下來，讓我談談資本配置。我們在 2023 年部署了均衡的資本配置。全年，我們的營運現金流為 94 億美元，而前一年為 85 億美元，增幅略低於 11%。今年資本支出略高於 47 億美元，符合我們的預期。年內，我們購買了約 38 億美元的已發行股票，並支付了約 6.6 億美元的股息。

Our debt to adjusted EBITDA leverage remains near the low end of our stated guidance range of 3x to 4x. So we believe we are well positioned going into 2024. And with that, let me speak to our 2024 guidance for a moment.

我們的債務與調整後 EBITDA 槓桿率仍接近我們規定的 3 倍至 4 倍指導範圍的低端。因此，我們相信我們已經做好了進入 2024 年的準備。接下來，讓我談談我們的 2024 年指導方針。

As noted in our release this morning, we are providing full year 2024 guidance as follows. We expect revenues to range between $67.75 billion and $70.25 billion. We expect net income attributable to HCA Healthcare range between $5.2 billion and $5.6 billion. We expect adjusted EBITDA to range between $12.85 billion and $13.55 billion and expect diluted earnings per share to range between $19.70 and $21.20. And finally, we expect capital spending to range between $5.1 billion and $5.3 billion.

正如我們今天上午發布的新聞稿中所指出的，我們提供 2024 年全年指導如下。我們預計營收將在 677.5 億美元至 702.5 億美元之間。我們預計 HCA Healthcare 的淨利潤在 52 億美元至 56 億美元之間。我們預計調整後 EBITDA 將在 128.5 億美元至 135.5 億美元之間，稀釋後每股收益將在 19.70 美元至 21.20 美元之間。最後，我們預計資本支出將在 51 億美元至 53 億美元之間。

So let me provide a little additional commentary on our guidance. First, let me note the $145 million payer settlement we reported in the first quarter of 2023. Our guidance assumes a growth in equivalent admissions between 3% and 4% and revenue per equivalent admission between 2% and 3%.

因此，讓我對我們的指導提供一些補充評論。首先，讓我注意一下我們在2023 年第一季報告的1.45 億美元的付款人和解。我們的指導假設同等入場人數增長3% 至4%，每次同等入場收入增長2% 至3% 。

Regarding state supplemental programs. I want to highlight that these programs are complex and most have multiple activities that impact the timing and amounts we receive. So this results in some variability of the timing of recognizing the impact of these programs during the year. For 2024, we are anticipating benefit from a new program in Nevada. But based on current assumptions, we expect some modest headwinds when we aggregate the impact of all of these supplemental programs and we believe this could range between $100 million and $200 million for the year.

關於國家補充計劃。我想強調的是，這些計劃很複雜，而且大多數都有多種活動，這些活動會影響我們收到的時間和金額。因此，這導致年內認識到這些計劃影響的時間存在一些變化。我們預計 2024 年將從內華達州的一項新計劃中受益。但根據目前的假設，當我們匯總所有這些補充計劃的影響時，我們預計會出現一些溫和的阻力，並且我們認為今年的阻力可能在 1 億至 2 億美元之間。

We expect full year margins to be within our historical trends and cash flow from operations to range between $9.5 billion and $10 billion. Depreciation estimated to be about $3.2 billion and interest expense is projected to be around $2 billion. Finally, our fully diluted shares are expected to be around $264 million for the year.

我們預計全年利潤率將符合歷史趨勢，營運現金流將在 95 億美元至 100 億美元之間。折舊預計約 32 億美元，利息支出預計約 20 億美元。最後，我們今年完全稀釋後的股份預計約為 2.64 億美元。

It was also noted in our release this morning, our Board of Directors has authorized a new $6 billion share repurchase program. This will be in addition to the approximately $300 million remaining on our prior authorization. In addition, our Board declared an increase in our quarterly dividend from $0.60 to $0.66 per share.

我們今天早上發布的新聞稿中還指出，我們的董事會已批准一項新的 60 億美元股票回購計畫。這將是我們事先授權中剩餘的約 3 億美元的補充。此外，我們的董事會也宣布將季度股息從每股 0.60 美元增加到 0.66 美元。

With that, let me turn the call back over to Sam.

接下來，讓我把電話轉回給 Sam。

All right. Thank you, Bill. As you saw in our press release, Bill Rutherford has decided to retire after 34 years with the company, 10 years as CFO and Bill had a tremendous career with HCA and then -- and my communication to our colleagues throughout the company I indicated that is impressive as the results work financially with the company during his tenure. Bill's legacy with the company will be remembered by the many people in the company has positively impacted with his leadership, mentorship in the way he embraced our mission and culture. And so Bill, congratulations on your retirement, and thank you very much on behalf of the Board and the senior team for everything you've done for the organization.

好的。謝謝你，比爾。正如您在我們的新聞稿中看到的那樣，Bill Rutherford 在公司工作了34 年、擔任財務長10 年後決定退休，Bill 在HCA 度過了輝煌的職業生涯，然後我與整個公司的同事進行了溝通，我表示：在他任職期間，公司的財務表現令人印象深刻。比爾為公司留下的遺產將被公司的許多人所銘記，他的領導力和指導對我們的使命和文化產生了積極的影響。比爾，恭喜您退休，並代表董事會和高階團隊非常感謝您為組織所做的一切。

Now part of Bill's legacy is creating a really deep financial team inside our organization. We pride ourselves on having the capabilities to build talent and then replace talent and we're fortunate to have Mike Marks as our next CFO. Mike has been with the company for 28 years. He has had various roles most of which were in the National Group at the Group for the National Group for 10 years, and then he's been in the Senior Vice President and Financial Operations role for the last few years. He is approved an HCA executive. He understands and appreciates our culture. He knows how to execute and get results. And I know he's going to be an exceptional CFO for HCA and I'm eager for many of you to get to meet him. And so Mike, congratulations.

現在，比爾遺產的一部分是在我們的組織內部創造一支真正深入的財務團隊。我們為擁有培養人才和替換人才的能力而感到自豪，我們很幸運有 Mike Marks 擔任我們的下一任財務長。 Mike 在公司工作 28 年。他曾擔任過各種職務，其中大部分是在國家集團的國家集團工作了 10 年，最近幾年他一直擔任高級副總裁兼財務運營職務。他被批准為 HCA 高管。他了解並欣賞我們的文化。他知道如何執行並取得結果。我知道他將成為 HCA 一位出色的財務官，我渴望你們中的許多人能夠見到他。麥克，恭喜你。

So with that Frank, we will go to questions.

那麼弗蘭克，我們將開始提問。

Thank you, Sam, and thank you, Bill. As a reminder, please limit yourself to one question so we might give as many as possible in the queue, an opportunity to ask a question. Greg, you may now give instructions to those who would like to ask a question.

謝謝你，山姆，謝謝你，比爾。提醒一下，請限制自己提出一個問題，以便我們為隊列中的盡可能多的人提供提問的機會。格雷格，你現在可以向那些想提問的人發出指示。

(Operator Instructions) Okay. It looks like our first question comes from the line of A.J. Rice with UBS.

（操作員指示）好的。看起來我們的第一個問題來自 A.J.賴斯與瑞銀。

Best wishes Bill, on the retirement and congratulations to Mike. I just want to ask about volumes because there's obviously some different chatter out there about what's going on. I think coming into the fourth quarter, you guys had said you expected to see a return to normal seasonality. I wonder whether that's what you described, what you saw there? Do you have any updated thoughts on whether we are seeing a sicker population post-COVID, maybe just some pent-up demand for people going back to see the doctors. And then specifically as well on utilization review management, we've talked about that from time to time that health plans are getting more aggressive post-pandemic now about utilization review. There's also a chatter in the last week about maybe there's actually easing observation status. I wonder if you could tell us a little bit of what you're seeing in that category as well.

衷心祝福比爾退休並祝賀麥克。我只是想問一下銷量，因為顯然對於正在發生的事情有一些不同的討論。我認為進入第四季度，你們曾說過預計會看到正常的季節性。我想知道這是否是你描述的、你在那裡看到的？對於新冠疫情後我們是否看到人口病情加重，您有什麼最新的想法嗎？也許這只是人們回去看醫生的一些被壓抑的需求。然後，特別是在利用率審查管理方面，我們不時地談到，疫情後的健康計劃在利用率審查方面變得更加積極。上週也有傳言稱觀察狀態可能實際上有所放鬆。我想知道您是否也可以告訴我們一些您在該類別中看到的內容。

Well, let's see, A.J., this is Sam. I have about 4 questions there. Let me see if I can sort of emphasize them. I will tell you from our judgment, we had normal seasonality with respect to most categories of our business. And we had indicated last year that we thought seasonality trends have returned in the latter half of 2022 and they continued in our estimation into the latter half of 2023 with the natural seasonality that we see in our outpatient areas as well as some of our other surgical areas for the most part, from the third quarter of this year to the fourth quarter.

好吧，讓我們看看，A.J.，這是山姆。我有大約 4 個問題。讓我看看是否可以強調它們。我會告訴你，根據我們的判斷，我們的大多數業務類別都有正常的季節性。我們去年曾表示，我們認為季節性趨勢已在 2022 年下半年回歸，並且我們的估計持續到 2023 年下半年，我們在門診區域以及我們的一些其他外科手術中看到了自然季節性。大部分地區是從今年第三季到第四季。

How that was influenced by new policies and pent-up demand, we can't really determine that, and we don't believe it had a material impact. So from our standpoint, we've been optimistic that our strategy around our network development, our execution on our quality and patient safety agendas and then our partnerships with our physicians was going to allow us to continue to grow. We mentioned that at our Investor Day and we think that's part and parcel to what's happening with our business as we push through the latter part of the year.

新政策和被壓抑的需求如何影響這一點，我們無法真正確定，我們認為它不會產生實質影響。因此，從我們的角度來看，我們一直樂觀地認為，我們圍繞網路發展的策略、我們對品質和病人安全議程的執行以及我們與醫生的合作夥伴關係將使我們能夠繼續發展。我們在投資者日提到了這一點，我們認為這是我們今年下半年業務發展的重要組成部分。

I mean there's always utilization of policies and procedures coming from the payers. There's like I said, some changes in certain policies. It's way too early to judge the effect of those and we are really judging our business and thinking about 2024 optimistically around where the demand for healthcare is at least in our markets.

我的意思是，付款人總是會利用政策和程序。正如我所說，某些政策發生了一些變化。現在判斷這些影響還為時過早，我們確實在判斷我們的業務，並樂觀地思考 2024 年至少在我們市場上的醫療保健需求。

Okay. Thank you. Our next question comes from the line of Pito Chickering with Deutsche Bank.

好的。謝謝。我們的下一個問題來自德意志銀行的 Pito Chickering。

Good morning, guys. Thanks for taking my questions. And Bill, it is a real pleasure working with you over the years. So thank you very much for all that.

早上好傢伙。感謝您回答我的問題。比爾，這些年來與您合作真的很愉快。非常感謝你們所做的一切。

On supplemental payments, so a lot of unpack there I guess. Can you bridge actually what the supplemental payments were in '22, '23 versus '24 in absolute dollars? And also on the OpEx side, how much the payment taxes were again for '22, '23 and '24?

關於補充付款，我猜那裡有很多拆包。您能否實際將 22 年、23 年和 24 年的補充付款金額以絕對美元計算？在營運支出方面，「22」、「23」和「24」的繳稅又是多少？

Yes. Pito, let me put it this way, I can't give you all that detail right now. As we've talked about -- we view supplemental payments is really just part of our overall Medicaid revenue portfolio. I think we're up to 17 or 18 states with supplemental payment programs right now. As I mentioned in my comments, each of these programs have a level of complexity, multiple attributes to it that affect the timing when we recognize those.

是的。 Pito，讓我這樣說，我現在無法向您提供所有詳細資訊。正如我們所討論的，我們認為補充付款實際上只是我們整體醫療補助收入組合的一部分。我認為目前有多達 17 或 18 個州制定了補充付款計劃。正如我在評論中提到的，每個程式都有一定程度的複雜性和多個屬性，這些屬性會影響我們識別這些程式的時間。

In the quarter, as I mentioned, we did recognize the benefit of the new North Carolina program that was anticipated. We had settlement in Texas and we began accruing Florida accounts for it. So we can maybe offline give you a quarter-by-quarter breakdown. But those were the main things that affected us during the fourth quarter. But I will mention even with the supplemental payment programs, the core operations of the business remains strong. When we look at core revenue growth as well as our revenue per admit growth, we believe the supplemental payments were just added to what was already a strong quarter.

正如我所提到的，在本季度，我們確實認識到了預期的新北卡羅來納州計劃的好處。我們在德克薩斯州定居，並開始在佛羅裡達州積累帳戶。因此，我們也許可以在線下為您提供逐季度的細分。但這些都是第四季影響我們的主要因素。但我要提到的是，即使有補充支付計劃，該業務的核心業務仍然強勁。當我們考慮核心收入成長以及每次入場收入成長時，我們認為補充付款只是在本已強勁的季度中添加的。

Okay. Our next question comes from the line of Justin Lake with Wolfe Research.

好的。我們的下一個問題來自賈斯汀·萊克 (Justin Lake) 與沃爾夫研究中心 (Wolfe Research) 的對話。

And I'll start off by adding my thanks to Bill to appreciate all the help over the years and you'll be missed and congrats to Mike.

首先，我要向比爾表示感謝，感謝多年來的所有幫助，我們會想念您的，並向麥克表示祝賀。

My question was around Medicare specifically and a couple of things. One, you talked about commercial being strong. We've been hearing Medicare and Medicare Advantage trends have been specifically really strong in the quarter. Can you give us some color on Medicare revenue growth and Medicare volume growth in the quarter? And then specifically, I think in reference to A.J.'s question, I think we just tried to touch on was the impact of the 2 midnight rule. Can you talk about what's going on there for 2024? And would you think the impact might be? And did you see any early benefits in 2023 as you started ramping up into this?

我的問題特別是關於醫療保險和一些事情。第一，你談到了商業的強勁。我們聽說醫療保險和醫療保險優勢趨勢在本季特別強勁。您能為我們介紹一下本季醫療保險收入成長和醫療保險數量成長嗎？然後具體來說，我認為關於 A.J. 的問題，我認為我們只是試圖觸及 2 點午夜規則的影響。您能談談 2024 年會發生什麼事嗎？您認為影響可能是什麼？當您開始加大投入時，您在 2023 年是否看到了任何早期的好處？

Yes, Justin, thanks for that. I will start with the Medicare volume, as I know that's been the topic. We have seen some growth in our Medicare Advantage admissions, which were roughly up 10% in the quarter, which is pretty consistent for what we've seen throughout the year. And we think this probably a combination of conversion from traditional Medicare fee-for-service. So all of some of our volume gains and maybe a bit utilization, it's hard for us to break that down in its entirety on there.

是的，賈斯汀，謝謝你。我將從醫療保險卷開始，因為我知道這是主題。我們看到 Medicare Advantage 入院人數有所增長，本季大約增加了 10%，這與我們全年看到的情況相當一致。我們認為這可能是傳統醫療保險按服務收費轉換的組合。因此，我們所有的一些銷售成長以及可能的利用率，我們很難將其全部分解。

In terms of our revenue per admit between Medicare Advantage and Medicare has been very consistent through the year as well. So we didn't see any really step change in the fourth quarter of that material amount. When I think about the 2 midnight rule, Sam alluded, it's too early for us to judge the impact of this rule. We know it's got a period to be implemented, we believe ultimately it's going to benefit our patients. And we think over time could be some moderate positive results for us. But we've seen no impact yet, but we believe over time, as we go through '24, there could be some modest benefit as we go through that.

就我們的每次入院收入而言，Medicare Advantage 和 Medicare 之間的收入全年也非常一致。因此，我們在第四季度沒有看到該材料數量有任何真正的階躍變化。 Sam 提到，當我想到午夜 2 點規則時，我們現在判斷該規則的影響還為時過早。我們知道它需要一段時間才能實施，我們相信它最終將使我們的患者受益。我們認為隨著時間的推移，可能會為我們帶來一些適度的正面成果。但我們還沒有看到任何影響，但我們相信，隨著時間的推移，當我們經歷 24 世紀時，我們可能會帶來一些適度的好處。

(Operator Instructions) And our next question comes from the line of Ben Hendrix with RBC Capital Markets. Ben, go ahead.

（操作員說明）我們的下一個問題來自 RBC Capital Markets 的 Ben Hendrix。本，繼續吧。

Thank you very much and congratulations to Bill and Mike. Just wanted to follow up on your comment about the $5 billion of capital spending you expect. I just wanted to get an idea of how you're thinking about allocating that into your inpatient capabilities and higher acuity. And where do you think how should we think about that evolving through the year? And the impact on case mix as we look into your 2024 guidance?

非常感謝並祝賀比爾和邁克。只是想跟進您對預期 50 億美元資本支出的評論。我只是想了解您如何考慮將其分配給您的住院能力和更高的敏銳度。您認為我們應該如何看待這一年的演變？當我們研究您的 2024 年指南時，這對個案組合有何影響？

This is Sam. We have been pretty consistent with our allocation over the years between inpatient, outpatient and technology. And I think 2024 will be somewhat consistent with that. I will tell you we do have a large development pipeline of new outpatient facilities that are connected to our capital project in 2024 and 2025, we'll have quite a few come online a little bit more than we had in '23 and '22. We do have some new hospitals in a few markets that will come online and we're starting to invest in other markets.

這是薩姆。多年來，我們在住院、門診和技術之間的分配一直非常一致。我認為 2024 年將與此有些一致。我會告訴你，我們確實有大量新門診設施的開發管道，這些設施與我們在2024 年和2025 年的資本項目相關，我們將有相當多的門診設施上線，比23 年和22 年的要多一點。我們確實在一些市場開設了一些新醫院，這些醫院將上線，我們也開始投資其他市場。

So I think when we look at the volume of beds and so forth coming on in '24, it's about the same as '23, if I remember correctly and then our ER capacity is growing consistently. So we're pretty consistent in our allocation of capital. It's not disproportionately oriented to any one category of our business. And we think, again, that approach has yielded really strong returns. It's allowed us to meet the demand expectations that exist in the market and it's also responded to our physicians in the way that created the capacity or allowed for the clinical technology that they need to practice their medicine.

因此，我認為，當我們查看 24 年的床位數量等時，如果我沒記錯的話，它與 23 年大致相同，然後我們的急診室容量正在持續增長。所以我們的資本配置非常一致。它並沒有不成比例地面向我們業務的任何類別。我們再次認為，這種方法已經產生了非常豐厚的回報。它使我們能夠滿足市場上存在的需求預期，並且還以創造能力或允許他們實踐醫學所需的臨床技術的方式對我們的醫生做出回應。

So we're stepping it up because we have a growing occupancy on the inpatient side. And then we have opportunities in the outpatient side to expand our networks further in these fast-growing communities. That's pretty much the snapshot of it but it's generally consistent from an allocation standpoint to prior years.

因此，我們正在加大力度，因為住院病人的入住率不斷增加。然後，我們在門診方面有機會在這些快速成長的社區中進一步擴展我們的網路。這幾乎是它的快照，但從分配的角度來看，它與前幾年基本一致。

Great. Thank you. And our next question comes from the line of Gary Taylor with TD Cowen. Gary, please go ahead.

偉大的。謝謝。我們的下一個問題來自 Gary Taylor 和 TD Cowen 的對話。加里，請繼續。

One clarification and then I'll ask my real question. I just want to make sure I understood what Bill said and congrats to Bill, by the way. You're walking through the net Medicaid DPP EBITDA outlook for '24. And I think you said, overall, you're expecting that dollars to come down $100 million to $200 million. I want to make sure I had that correct. And then my real question was just you talked about stemming the Valesco operating losses sequentially to more in line with what you originally thought, which I think means maybe brings that down to sort of breakeven in the quarter. And I was just hoping you'd share what us a little bit about how operational you pulled that off.

澄清一下，然後我會問我真正的問題。我只是想確保我理解比爾所說的話，並順便祝賀比爾。您正在瀏覽 24 年醫療補助 DPP EBITDA 淨前景。我認為您說過，總體而言，您預計資金將減少 1 億至 2 億美元。我想確保我的說法是正確的。然後我真正的問題是，您談到了將 Valesco 的營運虧損依次控製到更符合您最初的想法，我認為這意味著可能會在本季度達到盈虧平衡。我只是希望你能和我們分享你是如何實現這一目標的。

Yes, Gary, this is Bill. Thanks for those comments. I'll start with DPP, you are correct in my comments. We are expecting overall, when we aggregate all the programs to potentially be a headwind anywhere between $100 million and $200 million, largely due to settlements that we received this year, we don't expect to reoccur and then the Florida beginning accrual had an impact to that. So that's what's mostly driving that across our multiple programs.

是的，加里，這是比爾。感謝您的評論。我將從民進黨開始，你的評論是正確的。總體而言，我們預計，當我們將所有計劃匯總起來時，可能會產生1 億至2 億美元之間的逆風，這主要是由於我們今年收到的和解金，我們預計不會再次發生，然後佛羅裡達州的開始應計產生了影響對此。這就是我們多個專案的主要推動力。

On Valesco, as we mentioned, it came in line with our expectations, which think last quarter, we sized just under $50 million or so a quarter. As we continue to work on multiple improvement initiatives, including further integrating that joint venture into HCA. We expect to see continued improvement going forward. Next year, I think Valesco for the full year will equate with about the same amount we recorded this year, but we had 9 months this year versus 12 months obviously in 2024. So we do believe over time there will be continued improvement and we're working diligently towards those efforts.

正如我們所提到的，在 Valesco 上，它符合我們的預期，我們認為上季度我們每季的規模略低於 5,000 萬美元左右。我們將繼續致力於多項改善舉措，包括進一步將該合資企業整合到 HCA 中。我們期望看到未來持續改進。明年，我認為Valesco 全年的收入將與我們今年記錄的金額大致相同，但今年我們有9 個月，而2024 年顯然有12 個月。因此，我們確實相信，隨著時間的推移，將會持續改進，我們'正在為這些努力而努力。

Thank you. And our next question comes from the line of Brian Tanquilut with Jefferies.

謝謝。我們的下一個問題來自 Brian Tanquilut 和 Jefferies 的對話。

Bill, congrats on a very successful career at HCA. I guess my question to follow up on Gary's. Maybe expanding a bit further to the broader labor outlook. How are you thinking about the opportunity to further reduce spending on both nursing and obviously at Valesco? Or maybe another way to ask it is, how are you viewing inflation at the wage level?

Bill，恭喜您在 HCA 取得了非常成功的職業生涯。我想我的問題是對加里問題的跟進。也許進一步擴展到更廣泛的勞動力前景。您如何看待進一步減少護理支出以及瓦萊科支出的機會？或者換個方式問，您如何看待薪資水平的通膨？

Well, I think we've proven the teams have managed through that very well during the inflationary period we experienced. I think going forward, we expect to move back into kind of normal trends, which is generally 2.5% to 3% of wage inflation going forward. And then we believe there is continued improvement in contract labor to be achieved. And we have plans to execute that throughout 2024.

嗯，我認為我們已經證明，在我們經歷的通貨膨脹時期，團隊已經很好地解決了這個問題。我認為，展望未來，我們預計將回到正常趨勢，即未來薪資通膨率通常為 2.5% 至 3%。然後我們相信合約工的品質將會持續改善。我們計劃在 2024 年全年執行該計劃。

On the professional fees in Valesco, we have a number of initiatives with teams working on that only further integrate into our operations, but to continue to figure out adjustments to those programs. Our professional fees I've talked to, we have seen a decline in the sequential rate of growth. So we're a bit encouraged with that as we go into '24, we would expect those sequential declines to continue. And we're working hard through multiple initiatives, whether it be revenue enhancements, program adjustments or are looking at opportunities to internalize some of those programs.

關於瓦萊科的專業費用，我們與團隊一起制定了許多舉措，這些舉措只會進一步融入我們的運營，但會繼續找出對這些計劃的調整。我與我們交談過的專業費用顯示，我們看到環比成長率下降。因此，當我們進入 24 年時，我們對此感到有點鼓舞，我們預計這些連續下降將繼續下去。我們正在努力實施多項舉措，無論是增加收入、調整計劃，還是尋找將其中一些計劃內部化的機會。

Thank you. And our next question comes from Ann Hynes with Mizuho.

謝謝。我們的下一個問題來自瑞穗的安·海因斯。

I also want to congratulate Bill on his retirement. I just have a couple of follow-ups just on the managed care pricing yield assumptions for 2024, which is up 2% to 3%, which looks a little conservative given the 2 midnight rule and when you look at Medicaid redeterminations, the growth in the health exchange and your states are very strong. So in your guidance, do you embed any benefit from the 2 midnight rule or kind of the shift from Medicaid potentially to commercial?

我還要祝賀比爾退休。我只是對 2024 年管理式醫療定價收益率假設進行了一些後續跟踪，該假設上漲 2% 至 3%，考慮到 2 點午夜規則，這看起來有點保守，而且當你查看醫療補助重新確定時，健康交流和你們的國家都非常強大。那麼，在您的指導中，您是否嵌入了 2 點午夜規則或從醫療補助到商業的潛在轉變的任何好處？

And then secondly, if you can just maybe give us some more detail about how the 2 midnight rule could impact you, maybe a percent of our emissions or maybe kind of a differential between revenue per admit would be great.

其次，如果您能給我們更多關於午夜規則如何影響您的詳細信息，也許我們的排放量的百分比或每個承認的收入之間的差異會很大。

Yes, this is Bill. Let me first clarify, our 2% to 3% we mentioned earlier, it is our aggregated revenue per equivalent admission and then obviously, there's categories underneath it. I would tell you, regarding Medicaid redetermination is still early. We believe there's some modest benefit that we've seen as patients have migrated from Medicaid into HICS and other employer sponsors. I don't believe that's material yet. We'll see how that continues to trend throughout 2024. And I would say we don't have a material, in fact, material not factored into our guidance on that.

是的，這是比爾。首先讓我澄清一下，我們之前提到的 2% 到 3%，這是我們每同等入場費的總收入，然後顯然，它下面還有類別。我想告訴你，關於醫療補助的重新確定還為時過早。我們相信，隨著患者從醫療補助計劃轉向 HICS 和其他雇主資助計劃，我們已經看到了一些適度的好處。我不相信這還重要。我們將看到這一趨勢如何在 2024 年繼續發展。我想說的是，我們沒有任何材料，事實上，我們的指導中沒有考慮到這些材料。

On the 2 midnight rule, as we said earlier, it is really early in that progression. It should be positive for us if it's implemented as expected. I think it will be positive for patients over time as well. And we'll just have to see how that plays out. But we don't have, I'd say, a material adjustment factored into our '24 number for that as well. Our range of guidance, I think it accommodates for various outcomes on both of those programs and we'll see how that plays out as we go through the first part of the year.

關於 2 午夜規則，正如我們之前所說，現在確實處於該進展的早期階段。如果按預期實施，對我們來說應該是正面的。我認為隨著時間的推移，這對患者也會產生正面的影響。我們只需要看看結果如何。但我想說，我們也沒有對此進行重大調整，並將其納入我們的 24 數字中。我認為我們的指導範圍適應了這兩個計劃的各種結果，我們將在今年上半年看到結果如何。

(Operator Instructions) And our next question comes from Whit Mayo with Leerink Partners.

（操作員說明）我們的下一個問題來自 Leerink Partners 的 Whit Mayo。

Thanks. And congrats to Bill. I think this might be the second time you've retired. So I hope it sticks. But my question really, Sam, is I'm curious on any new expense initiatives that you guys have elevated internally as a new strategic focus, anything, maybe more creative or imaginative that you're bringing forth this year to challenge the organization.

謝謝。並祝賀比爾。我想這可能是你第二次退休了。所以我希望它能堅持下去。但薩姆，我真正的問題是，我對你們在內部將其提升為新的戰略重點的任何新的支出計劃感到好奇，或者你們今年提出的挑戰組織的任何可能更具創造性或想像力的計劃。

Well, at our Investor Day, Mike Marks presented our financial resiliency program and it's got different components to it. There's more sophisticated integration of our revenue cycle that includes our case management initiative, which I will highlight here. Our case management initiative is to make sure that our patients get into the right setting in the right time line and free up capacity where appropriate. And so for this past year, we had early-stage success with that. Our length of stay was down and our case mix was modestly up. So when you put the 2 together, it's a good start for us with respect to our case management initiative. That is important on multiple fronts. It allows us to allocate our nurse staffing more effectively to more acute patients and so forth. We will continue to invest in that initiative as we bring on more technology, more structure to our teams and better process in benchmarking.

嗯，在我們的投資者日，麥克馬克斯介紹了我們的財務彈性計劃，它有不同的組成部分。我們的收入週期有更複雜的整合，包括我們的案例管理計劃，我將在這裡強調這一點。我們的個案管理措施是確保我們的患者在正確的時間進入正確的環境，並在適當的情況下釋放能力。因此，在過去的一年裡，我們在這方面取得了早期階段的成功。我們的停留時間縮短了，病例組合略有增加。因此，當您將兩者放在一起時，這對我們的案例管理計劃來說是一個很好的開始。這在多個方面都很重要。它使我們能夠更有效地將護理人員分配給更急症的患者等。隨著我們為我們的團隊帶來更多技術、更多結構和更好的基準測試流程，我們將繼續投資於該計劃。

The second thing I would highlight is with respect to what we're calling our internal benchmarking initiative. We have incredible opportunities to compare more deeply into our organization, whether it's on the variable cost side with respect to what we allocate and distribute to our facilities or on fixed costs. And both of those categories are getting a lot more benchmarking under Mike's leadership, and we're finding opportunities to rethink how we organize our cost structure, how we leverage process improvement, how we use technology and automation in those areas to improve processes and variable costs. So I'm excited about the prospects there.

我要強調的第二件事是我們所謂的內部基準測試計畫。我們有難以置信的機會更深入地比較我們的組織，無論是在我們分配和分配給我們的設施的可變成本方面還是在固定成本方面。在麥克的領導下，這兩個類別都獲得了更多的基準測試，我們正在尋找機會重新思考如何組織成本結構、如何利用流程改進、如何在這些領域使用技術和自動化來改善流程和變數成本。所以我對那裡的前景感到興奮。

As I mentioned in my commentary, we had a very successful transition from the third quarter to the fourth quarter with respect to what we call clearance operating leverage and our operating leverage from the third quarter to the fourth quarter was the best I've seen in my experiences with the company. And I think part of that, not all of that is due to some of these initiatives and the transparency we have around our efforts to improve efficiencies, improve clinical outcomes for our patients and so forth.

正如我在評論中提到的，就我們所說的清算營運槓桿而言，我們從第三季到第四季的過渡非常成功，我們從第三季到第四季的營運槓桿是我所見過的最好的。我在公司的經驗。我認為部分原因（並非全部原因）是由於其中一些措施以及我們在提高效率、改善患者臨床結果等方面的努力所具有的透明度。

So those are 2 things I would highlight. Obviously, our technology agenda and our care transformation is a longer-run effort with respect to improved outcomes across different dimensions of our business. And we had some modest success there in the short run. We're really banking on those programs giving us long-term value. So those are just a couple of highlights, Whit.

這是我要強調的兩件事。顯然，我們的技術議程和護理轉型是一項長期努力，旨在改善我們業務不同層面的成果。短期內我們在這方面取得了一些小小的成功。我們確實指望這些計劃能為我們帶來長期價值。惠特，這些只是幾個亮點。

I will tell you, our teams culturally are disciplined. And as I mentioned, that discipline creates opportunities for us to find better ways to do things for all of our stakeholders. And that mindset is something that we carry forward from 1 year to the next, then we'll carry that on into '24 and into '25 and so forth. And we think it's an essential ingredient for a health system success. And I'm pretty proud of our teams and how they embrace that and how they execute on the initiatives to make that happen.

我會告訴你，我們的團隊在文化上是有紀律的。正如我所提到的，這種紀律為我們創造了機會，讓我們能夠找到更好的方法來為所有利害關係人做事。我們將這種心態從一年延續到下一年，然後我們將把它延續到 24 年和 25 年，依此類推。我們認為這是衛生系統成功的重要因素。我為我們的團隊以及他們如何擁抱這一點以及他們如何執行實現這一目標的舉措感到非常自豪。

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

我們的下一個問題來自美國銀行的 Kevin Fischbeck。

Great. And I'll just add my thanks to Bill for your help over the years. I guess I wanted to know -- get a little more color from you guys about the volume expectation for 2024 because it's -- you guys want talk about 2% to 3% you're looking for faster growth in '24. So I just wanted to better understand where that extra growth is coming from. So any color on the service lines or procedures that you think still have room to grow above average? And if there's anything that you'd expect from a payer mix perspective in '24? Is there one type of payer where you think there's a big opportunity for volumes to snap back?

偉大的。我還要感謝比爾多年來的幫忙。我想我想知道——從你們那裡得到更多有關 2024 年銷量預期的信息，因為——你們想要談論 2% 到 3% 的事情，你們希望在 24 年實現更快的增長。所以我只是想更好地了解額外的增長來自哪裡。那麼，您認為服務線或程式上的任何顏色仍有成長空間高於平均水平嗎？從付款人組合的角度來看，您對 24 年有什麼期望嗎？您認為是否有一種付款人的交易量有很大機會回升？

Kevin, let me start and then Sam can add in. So we're going off our experience we've seen throughout '23. As we said earlier in the comments, we thought there was very strong demand for services in our markets. We think our capital programs and our program initiatives are paying off. Our adjusted admissions this year were 4.8%. You're right in our guidance next year, caused us for 3% to 4% expectation on adjusted admissions that may be a little higher than our 2% to 3% historical. But I think we're reading continued strong demand. We saw really strong enrollment in the health insurance exchanges across our states. And that continues to be a favorable development for us. We believe we continue to see strong economic indicators and employments and our access to contracted lives remaining wells. So I think all of those factors go into play with our expectations for '24 and is based on kind of our current experience.

Kevin，讓我開始，然後 Sam 可以補充。所以我們將繼續我們 23 年以來的經驗。正如我們之前在評論中所說，我們認為我們的市場對服務的需求非常強勁。我們認為我們的資本計劃和計劃舉措正在取得回報。我們今年調整後的錄取率為 4.8%。你在我們明年的指導中是正確的，這使我們對調整後的入學人數的預期為 3% 至 4%，這可能略高於我們的歷史 2% 至 3%。但我認為我們看到了持續強勁的需求。我們看到各州健康保險交易所的註冊人數非常多。這對我們來說仍然是一個有利的發展。我們相信，我們繼續看到強勁的經濟指標和就業以及我們獲得合約壽命的機會仍然良好。因此，我認為所有這些因素都會影響我們對 24 世紀的期望，並且基於我們目前的經驗。

And our next question comes from the line of Stephen Baxter with Wells Fargo.

我們的下一個問題來自富國銀行的史蒂芬‧巴克斯特（Stephen Baxter）。

Congrats to Bill as well. I was hoping you could talk a little bit about surgical growth in the quarter, whether there's any notable puts or takes there by service line or inpatient versus outpatient? And then I guess, the overall growth slowed down a little bit as we got through the back half of the year. I guess, how are you thinking about surgical growth in 2024, especially coming up against maybe some of the tougher comparisons that you'll have in the first half of the year.

也恭喜比爾。我希望您能談談本季的外科手術成長，服務線或住院與門診是否有任何顯著的成長或下降？然後我想，隨著下半年的到來，整體成長速度有所放緩。我想，您如何看待 2024 年的手術成長，尤其是面對今年上半年可能會進行的一些更艱難的比較。

So overall, the fourth quarter surgery was a little slower than the year-to-date, and we were talking about that earlier this morning. We did have a more difficult December calendar, even though we had the same surgical days in total, the way they were allocated, created some challenges in our outpatient settings that we saw outpatient activity not as strong as in the previous 2 months of the quarter. But at a structural level, there's nothing to suggest that our surgical volume trends are going to change for the year, we had really solid volume growth in surgery. And we continue to invest heavily in our programs, both on the outpatient side and supporting our inpatient activity with more acute in complex program offerings.

總的來說，第四季度的手術比今年迄今為止要慢一些，我們今天早上早些時候就討論過這一點。我們確實有一個更困難的 12 月日曆，儘管我們總共有相同的手術天數，但它們的分配方式給我們的門診環境帶來了一些挑戰，我們發現門診活動不如本季度前 2 個月那麼強勁。但在結構層面上，沒有任何跡象顯示我們今年的手術量趨勢會發生變化，我們的手術量確實出現了穩健的成長。我們繼續大力投資我們的項目，無論是在門診方面，還是透過更敏銳的複雜項目產品來支持我們的住院活動。

And for the year, our inpatient surgeries were up 2%, and our outpatient surgeries were up 2.5% so a slight migration, if you will, into the outpatient setting. And we think that will be generally consistent as we push into 2024. We do have a number of ambulatory surgery centers that have opened or will open in 2024. We've made a few acquisitions in certain markets with ambulatory surgery centers, and we continue to invest in our hospital operating suite as well as improve our processes just as we are improving our emergency room process with our revitalization program, and we think that will continue to be a value-add for our patients and for our physicians and help us with our volume pursuits.

今年，我們的住院手術量增加了 2%，門診手術量增加了 2.5%，因此，如果您願意的話，會有輕微的遷移到門診環境。我們認為，隨著我們進入2024 年，這種情況將基本保持一致。我們確實有許多門診手術中心已經開業或將在2024 年開業。我們在某些​​市場上對門診手術中心進行了一些收購，我們將繼續投資我們的醫院手術室並改進我們的流程，就像我們透過振興計劃改進急診室流程一樣，我們認為這將繼續為我們的患者和醫生帶來增值，並幫助我們我們對數量的追求。

So that's how we're judging the surgical space. If you look at cardiac underneath that, our cardiac volumes continue to grow very robust and are actually growing in the mid-single digits and we think, again, that's reflective of our overall program development, expansion into new service lines underneath cardiac in responding again to our patient needs and physician needs and ways and we believe are productive for our organization.

這就是我們判斷手術空間的方式。如果你看看下面的心臟，我們的心臟容量繼續增長非常強勁，並且實際上以中等個位數增長，我們認為，這再次反映了我們的整體計劃開發，擴展到心臟下的新服務線以再次做出反應滿足我們患者的需求和醫生的需求以及我們相信對我們的組織富有成效的方式。

Excellent. Our next caller -- or excuse me, our next question comes from the line of Jason Cassorla with Citigroup. Jason, please go ahead.

出色的。我們的下一個來電者——或者對不起，我們的下一個問題來自花旗集團的賈森·卡索拉（Jason Cassorla）。傑森，請繼續。

Best of luck in your retirement, Bill. I just wanted to follow up on the professional fee environment. You noted there was some deceleration in professional fee spend growth, if I heard that correctly. But maybe what is your expectation for physician costs or professional fees growth embedded within '24 guidance? And then on Valesco, it sounds like in your comments, Bill, that Valesco would generate $150 million of negative EBITDA next year versus the $200 million or so headwind for '23? Is that a fair way to look at it? Or any other color there would be great.

祝你退休生活好運，比爾。我只是想跟進專業費用環境。如果我沒聽錯的話，您注意到專業費用支出成長放緩。但也許您對「24 小時指南」中包含的醫生費用或專業費用增長的預期是什麼？然後，關於 Valesco，比爾，在您的評論中，Valesco 明年將產生 1.5 億美元的負 EBITDA，而 23 年的逆風約為 2 億美元？這是一個公平的看待它的方式嗎？或者任何其他顏色都會很棒。

Yes. Let me add in, and thanks. I think Valesco is a little lower. We're about $150 million in both years. But obviously, in '23, we had 9 months versus full month 12 months next year. So we see a kind of a run rate improvement as we go through the quarters during the year.

是的。讓我補充一下，謝謝。我認為瓦萊斯科的水平要低一些。兩年我們的收入約為 1.5 億美元。但顯然，23 年我們有 9 個月，明年則有 12 個月。因此，當我們經歷一年中的各個季度時，我們看到運行率有所改善。

On pro fees, we, as we said, have seen a decline in the sequential rate of growth. We have multiple initiatives underway. Embedded in our guidance next year is holding that professional fee growth perhaps to 8% to 10% versus this year, where it's been closer to 15% to 20%. So we are looking for a step changing. We're confident in our initiatives and the activities we have to be able to begin to bend that trend line.

在專業費用方面，正如我們所說，我們看到環比成長率有所下降。我們正在進行多項措施。我們明年的指導方針是，與今年相比，專業費用成長可能為 8% 至 10%，今年接近 15% 至 20%。所以我們正在尋找改變的一步。我們對我們的舉措和活動充滿信心，我們必須能夠開始扭轉這一趨勢線。

Great. And our next question comes from Scott Fidel with Stephens. Scott, please go ahead.

偉大的。我們的下一個問題來自斯科特·菲德爾和史蒂芬斯。斯科特，請繼續。

I'll echo my congrats to Bill. And then my question is would be curious in terms of how you're thinking about the whole broader debate on just the pent-up demand recovery in the seniors population. And based on all your data and analysis, sort of where you think the Medicare utilization trends are now at this point relative to sort of pre-pandemic levels and returning to the baseline, certainly felt like there was some, quite a bit of that recovery played out in '23. But interested in sort of what inning you think we may be in that process at this point.

我將向比爾表示祝賀。然後我的問題是，您如何看待有關老年人口被壓抑的需求復甦的整個更廣泛的辯論。根據您所有的數據和分析，您認為目前醫療保險利用率趨勢相對於大流行前的水平並返回到基線，當然感覺有一些、相當多的復甦23年播出。但對你認為我們目前可能處於過程中的哪一局感興趣。

This is Sam. It's interesting, I'm just looking at a trend line here. I don't have it beyond this time period. But in 2019, this is a composite view of Medicare. So it has both Medicare and Medicare Advantage. It's our Medicare admissions grew 2.6%. You throw out 2020 and 2021 grew 2.1%. 2022 grew 3.4% and 2023 grew 4%. So is there acceleration on our trend? Yes. Obviously, there's aging baby boomers in the mix there, number one. Number two, we think we're taking out market share. So to judge overall utilization patterns around that is really difficult for us. There's population growth in our markets. When you look at adjusted admissions, on the same combination payer class. Again, 3.7% in 2019, 5.3% at '21, 4.7% in '22 and 5.7% in '23.

這是薩姆。很有趣，我只是在這裡看一條趨勢線。超過這個時段我就沒有了。但在 2019 年，這是對 Medicare 的綜合看法。所以它同時具有Medicare和Medicare Advantage。我們的醫療保險入院人數增加了 2.6%。撇開 2020 年，2021 年成長了 2.1%。 2022 年成長 3.4%，2023 年成長 4%。那我們的趨勢有加速嗎？是的。顯然，第一，其中有老化的嬰兒潮世代。第二，我們認為我們正在奪取市場份額。因此，判斷整體利用率模式對我們來說確實很困難。我們的市場人口正在成長。當你查看調整後的招生時，會發現在相同的組合付款人類別中。同樣，2019 年為 3.7%，21 年為 5.3%，22 年為 4.7%，23 年為 5.7%。

So a slight acceleration, but a function, we believe of aging baby boomers and a number of beneficiaries moving in the program, population growth for us in market share gains. So it's hard for us to judge underneath that, whether or not there's some structural change in utilization, that's almost impossible for us to discern with the data that we have.

因此，略有加速，但我們相信，老齡化的嬰兒潮一代和許多受益者加入該計劃，人口增長為我們帶來了市場份額的增長。因此，我們很難從根本上判斷，利用率是否存在一些結構性變化，我們幾乎不可能用現有的數據來辨別。

Great. Thank you, Scott. And our next question comes from the line of Sarah James with Cantor Fitzgerald.

偉大的。謝謝你，斯科特。我們的下一個問題來自莎拉·詹姆斯和康托·菲茨杰拉德的台詞。

Congratulations on the retirement Bill. You guys said that the impact of the 2 midnight rule ramps through the year. So ramp as opposed to flipping a switch. What are the mechanics of that stage implementation? Is it retaining your staff? Or is it assuming some delay in benefit from claims denials and getting the payers on board? And then when would it be fully ramped? Are you talking midyear exiting 2024? And is there anything that HCA can do to pull that forward?

恭喜退休法案通過。你們說，2 午夜規則的影響在全年中不斷增加。因此，斜坡而不是翻轉開關。此階段實施的機制是什麼？它能留住你的員工嗎？還是假設索賠被拒絕帶來的福利延遲並讓付款人參與其中？那麼什麼時候才能全面啟動呢？您是在談論 2024 年年中退出嗎？ HCA 可以做些什麼來推動這項進程嗎？

Well, I mean, the rule goes in effect in January. So I think the impact may ramp over time. It's a notable change for the payers. So we're working them very closely on the administration of those plans and making sure it's operating as described on there. And if it does, we should see it equally throughout the year. And so we're working closely on it, but it's a pretty big change for the payers. And so there might be some administrative differences as it gets implemented through the year. But we hope very quickly, we'll be able to work our way through that and begin to see some benefit as we go through 2024.

嗯，我的意思是，該規則將於一月份生效。所以我認為影響可能會隨著時間的推移而增加。對於付款人來說，這是一個顯著的變化。因此，我們正在與他們密切合作來管理這些計劃，並確保其按照其中所述進行運作。如果確實如此，我們全年都會看到同樣的情況。因此，我們正在密切合作，但這對付款人來說是一個相當大的變化。因此，在全年實施過程中可能會存在一些行政差異。但我們希望很快就能解決這個問題，並在 2024 年開始看到一些好處。

Thanks, Sarah. And our next question comes from Lance Wilkes with Bernstein.

謝謝，莎拉。我們的下一個問題來自伯恩斯坦的蘭斯威爾克斯。

Congratulations to both Bill and Mike. Can you talk a little bit about labor supply that you're seeing? First, in the past, a couple of quarters ago, I talked about like demand that have been turned away at the hospitals. If you could just note if there's still any of that. And then how kind of hiring pipelines and are there particular areas that are more plentiful or areas that might be bottlenecks?

恭喜比爾和邁克。您能談談您所看到的勞動力供應嗎？首先，在過去，幾個季度前，我談到了醫院拒絕的類似需求。如果你能注意到是否還有這樣的情況就好了。那麼招募管道是怎麼樣的？是否有一些特定領域比較充足或可能存在瓶頸？

This is Sam again. Thank you for the question. We finished the year roughly, I don't have the exact average here at 90% acceptance rate. In other words, we weren't able to take roughly 10% of the patients who were referred to us through our transfer centers and such. That improved throughout the year as we went from maybe the mid-to-high in the first part of the year, to a little better than that in the second half of the year. We're still below where we were in 2019. But what we have seen is more patients coming through our transfer centers and other patient navigation program that we did in 2019. So we feel good about the inflow, if you will.

這又是薩姆。感謝你的提問。我們大致結束了這一年，我這裡沒有 90% 的錄取率的準確平均值。換句話說，我們無法接收透過轉運中心等轉診到我們的大約 10% 的患者。這一情況在全年都有所改善，我們從上半年的中高水平，到了比下半年稍好的水平。我們仍低於 2019 年的水平。但我們看到更多的患者透過我們的轉運中心和我們在 2019 年實施的其他患者導航計劃。因此，如果您願意的話，我們對流入感到滿意。

We are still at times in situations where all of our capacity is not open and available, and that's what generates these situations where we can't receive the patients that are coming through these navigation programs and transfer centers. We think that will continue to get better in '24 as we have capital coming online as our hiring patterns continue to improve. Our turnover, as I mentioned in my commentary, has also improved. We've been very intentional in trying to create a great environment for our people with good leadership, resource capabilities and just overall trading to support the efforts so that they can be successful in what they do. And we think that will help us push through '24 and hopefully have more capacity available and be able to receive the patients that want to get into our system.

有時，我們仍然面臨著所有能力均未開放和可用的情況，這就是導致我們無法接收透過這些導航程序和轉運中心而來的患者的情況的原因。我們認為，隨著我們的招募模式不斷改善，我們的資本將在 24 年繼續改善。正如我在評論中提到的，我們的營業額也有所改善。我們一直非常有意識地努力為我們的員工創造一個良好的環境，擁有良好的領導力、資源能力和整體貿易來支持我們的努力，以便他們能夠在工作中取得成功。我們認為這將幫助我們度過 24 年，並希望有更多的可用容量並能夠接收想要進入我們系統的患者。

Great. And our next question comes from the line of Josh Raskin with Nephron Research.

偉大的。我們的下一個問題來自 Nephron Research 的 Josh Raskin。

Bill, and congratulate on him on the retirement, and congrats to Mike as well. Could you speak to the increase in CapEx guidance again, this has been a multiyear trend for you guys? And maybe how returns on CapEx have trended? I'm just curious if there's more mix to outpatient, is that actually improving returns or are you getting to a point where the returns are coming in a little bit lower for the incremental project as you sort of continue to go down the list?

比爾，祝賀他退休，也祝賀麥克。您能否再次談談資本支出指引的增加，這對你們來說是多年的趨勢？也許資本支出的報酬趨勢如何？我只是很好奇，門診是否有更多的組合，這是否真的提高了回報，或者當你繼續沿著清單往下走時，增量項目的回報是否會降低一點？

Josh, this is Bill. I'll start on the returns. Our returns remain very solid. I mean, we're in the upper teens returns. We have a very disciplined process where we evaluate these projects and we actually do look backs to validate some of our assumptions. And to me, the growth in the capital spending is a reflection of the growth of the opportunities we see to deploy capital to continue that growth. So we're very pleased with the returns on those.

喬什，這是比爾。我將從回報開始。我們的回報仍然非常穩定。我的意思是，我們正處於十幾歲的回報期。我們有一個非常嚴格的流程來評估這些項目，我們實際上會回顧來驗證我們的一些假設。對我來說，資本支出的成長反映了我們看到的部署資本以繼續成長的機會的成長。所以我們對這些回報非常滿意。

I think as Sam mentioned earlier in the Q&A, the mix between inpatient and outpatient, it varies from time to time, but mostly similar. We do have some newer outpatient facilities coming on. They generally have very good returns and quick returns when they do come online. So I think the capital program we're pleased with. It's an important component to our growth formula, as we've talked about and we're pleased with the overall returns in the interview.

我認為正如薩姆之前在問答中提到的那樣，住院病人和門診病人之間的混合，有時會有所不同，但大多相似。我們確實有一些新的門診設施即將投入使用。他們上線後通常都會有很好的回報，而且回報也很快。所以我認為我們對資本計劃感到滿意。正如我們所討論的，這是我們成長公式的重要組成部分，我們對訪談中的整體回報感到滿意。

Yes. And the only thing I would say, and Bill alluded to this, our outpatient platform tends to be short cycle returns. We get a real efficient sort of capital allocation with outpatient facilities. And then on the hospital side, we are a hospital-centric health system. And as we invest in our hospitals, those are long-lived assets and they have a longer cycle to them with respect to returns, but they're critically important to the overall value that our outpatient facilities can generate for our system in the sense that we're able to navigate the patient further into the healthcare system if they need more acute care offerings. So we have to look at it in both manners.

是的。我唯一要說的是，比爾也提到了這一點，我們的門診平台往往是短週期回報。我們透過門診設施實現了真正有效的資本配置。然後在醫院方面，我們是一個以醫院為中心的衛生系統。當我們投資醫院時，這些都是長期資產，它們的回報週期更長，但它們對於我們的門診設施可以為我們的系統產生的整體價值至關重要，因為如果患者需要更多的急診護理服務，我們可以引導他們進一步進入醫療保健系統。所以我們必須從兩個方面來看待它。

I think to Bill's point, we have had strong returns, a pattern of strong returns, we have occupancy on our inpatient hospital side in the low 70%, which is a pretty high occupancy level up over where it was pre-pandemic even with the additional beds that we've added. So we think the network model that we highlighted for you all at the Investor Day is working and is complemented by the outpatient facilities integrated with the hospital system in a manner that produces really positive enterprise returns for our company.

我認為按照比爾的觀點，我們獲得了強勁的回報，一種強勁回報的模式，我們住院醫院的入住率只有 70%，這比大流行前的入住率水平相當高，即使在我們添加的額外床位。因此，我們認為我們在投資者日向大家強調的網路模式正在發揮作用，並輔以與醫院系統整合的門診設施，從而為我們公司帶來了真正積極的企業回報。

Great. And our final question comes from the line of Cal Sternick with JPMorgan.

偉大的。我們的最後一個問題來自卡爾·斯特尼克與摩根大通的對話。

I'll add my congratulations to Bill as well. So 2 follow-ups. First, on the redeterminations. It sounds like that's a slight benefit to the 2024 guide, but not really material yet. Just wanted to clarify if this does develop better than you're anticipating? Is it something you think could be material to 2024? Or is the upside more annualized in 2025 after the redeterminations are completed.

我也會向比爾表示祝賀。所以有 2 個後續行動。首先，關於重新確定。聽起來這對 2024 年指南來說是一個小小的好處，但還不是實質的。只是想澄清這是否比您預期的發展得更好？您認為這對 2024 年可能很重要嗎？或者在重新確定完成後，2025 年的上漲空間會更大。

And then my other question was on the quarter itself. So one of the payers called out higher COVID inpatient costs per case. Can you talk about the COVID acuity levels that you saw in the quarter and whether that developed consistently with what you've seen in the past?

然後我的另一個問題是關於季度本身的。因此，其中一位付款人表示，每例新冠肺炎住院費用更高。您能否談談您在本季度看到的新冠病毒嚴重程度以及其發展是否與您過去看到的一致？

Yes. This is Bill. Let me start with the Medicaid redetermination. I think you're characteristic is right we do, see some modest benefit in 2024. We haven't adjusted to be material yet, but our range of guidance allows for some outcomes on there. We started to see some of the effects of those redeterminations late in 2023. We're tracking those very closely. We're seeing roughly 30% to 35% of those individuals that were potentially lost Medicaid seem to show up with either HICS or employer-sponsored coverage so that there's some benefit in that. We're seeing a decently large number being able to be reapplied in the Medicaid because some were redetermined off for technical reasons. So we've been able to manage through that.

是的。這是比爾。讓我從醫療補助重新確定開始。我認為你的觀點是正確的，我們確實會在 2024 年看到一些適度的好處。我們尚未調整到實質的程度，但我們的指導範圍允許在那裡取得一些成果。我們在 2023 年底開始看到這些重新決定的一些影響。我們正在非常密切地追蹤這些影響。我們發現，大約 30% 到 35% 的可能失去醫療補助的人似乎都獲得了 HICS 或雇主贊助的保險，因此這有一些好處。我們看到相當多的人能夠在醫療補助中重新申請，因為有些人因技術因素被重新確定。所以我們已經能夠解決這個問題。

And I think with the conversion into either HICS or employer-sponsored, there is some modest benefit as we go through the year. And potentially, that will continue as we go through 2024 but don't judge that to be material at this stage.

我認為，無論是轉換為 HICS 還是由雇主資助，在這一年中都會帶來一些適度的好處。這種情況可能會持續到 2024 年，但現階段並不認為這是實質的。

Regarding COVID, to be honest with you, COVID has really been stable for us over the past year. In total, our COVID admissions are roughly 2% of our total admissions. I don't really have any data on acuity, but I think it's very, very stable and hasn't really been a material factor in our overall operating results of late.

關於新冠病毒，說實話，過去一年來，新冠病毒對我們來說確實很穩定。總的來說，我們的新冠肺炎入院人數約佔總入院人數的 2%。我確實沒有任何關於敏銳度的數據，但我認為它非常非常穩定，並且並不是我們最近整體營運表現的重要因素。

Great. Thanks, all. And that does conclude our question-and-answer session. I would now like to turn it over to Frank for closing remarks. Frank, the floor is yours.

偉大的。謝謝大家。我們的問答環節到此結束。現在我想請法蘭克作結束語。法蘭克，地板是你的。

Sure. Great. Thank you for your help today, and thanks to everyone for joining us on the call. Hope you have a wonderful week, and we'll be around this afternoon and the balance of the week if we can answer any additional questions you might have. Have a good day.

當然。偉大的。感謝您今天的幫助，也感謝大家加入我們的電話會議。希望您度過愉快的一周，如果我們可以回答您可能有的任何其他問題，我們將在今天下午和本週的剩餘時間中進行答案。祝你有美好的一天。

And ladies and gentlemen, that does conclude today's call. Thank you all for joining and you may now disconnect.

女士們、先生們，今天的電話會議到此結束。感謝大家的加入，現在可以斷開連線了。