Tenet Healthcare Corp (THC) 2023 Q1 法說會逐字稿

Good morning, and welcome to the Tenet Healthcare First Quarter 2023 Earnings Conference Call. (Operator Instructions)

早上好，歡迎來到 Tenet Healthcare 2023 年第一季度收益電話會議。 （操作員說明）

I'll now turn the call over to your host, Mr. Will McDowell, Vice President of Investor Relations. Mr. McDowell, you may begin.

我現在將電話轉給你的東道主，投資者關係副總裁威爾麥克道爾先生。麥克道爾先生，您可以開始了。

Good morning, everyone, and thank you for joining today's call. I am Will McDowell, Vice President of Investor Relations. We're pleased to have you join us for a discussion of Tenet's first quarter 2023 results as well as a discussion of our financial outlook.

大家早上好，感謝您參加今天的電話會議。我是投資者關係副總裁 Will McDowell。我們很高興您能與我們一起討論 Tenet 2023 年第一季度的業績以及我們的財務前景。

Tenet senior management participating in today's call will be Dr. Saum Sutaria, Chief Executive Officer; and Dan Cancelmi, Executive Vice President and Chief Financial Officer. Our webcast this morning includes a slide presentation, which has been posted to the Investor Relations section of our website, tenethealth.com.

參加今天電話會議的 Tenet 高級管理人員將是首席執行官 Saum Sutaria 博士；執行副總裁兼首席財務官 Dan Cancelmi。我們今天上午的網絡廣播包括一個幻燈片演示，已發佈到我們網站 tenethealth.com 的投資者關係部分。

Listeners to this call are advised that certain statements made during our discussion today are forward-looking and represent management's expectations based on currently available information. Actual results and plans could differ materially. Tenet is under no obligation to update any forward-looking statements based on subsequent information. Investors should take note of the cautionary statement slide included in today's presentation as well as the risk factors discussed in our most recent Form 10-K and other filings with the Securities and Exchange Commission.

本次電話會議的聽眾請注意，在我們今天的討論中所做的某些陳述是前瞻性的，代表了管理層基於當前可用信息的預期。實際結果和計劃可能存在重大差異。 Tenet 沒有義務根據後續信息更新任何前瞻性陳述。投資者應注意今天演示文稿中包含的警告聲明幻燈片，以及我們最近向美國證券交易委員會提交的 10-K 表格和其他文件中討論的風險因素。

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

有了這個，我會把電話轉給 Saum。

Thank you, Will. And good morning, everyone. We're off to a nice start for 2023. Strong volumes support good results in all 3 business units. USPI's performance continues to accelerate given our focus on organic growth and is ahead of our expectations so far. In the first quarter, we delivered net operating revenues of $5 billion and consolidated adjusted EBITDA of $832 million, which translates into an attractive 16.6% margin.

謝謝你，威爾。大家早上好。我們在 2023 年有了一個良好的開端。強勁的銷量支持所有 3 個業務部門的良好業績。考慮到我們對有機增長的關注，USPI 的業績繼續加速增長，並且超出了我們的預期。第一季度，我們實現了 50 億美元的淨營業收入和 8.32 億美元的綜合調整後 EBITDA，轉化為 16.6% 的誘人利潤率。

As a result of our strong performance in the first quarter, we are now raising our full year guidance, which demonstrates the confidence we have in our operations. Across our businesses, a post-pandemic environment is taking shape. COVID admissions are down, a wider range of acuity is returning to the hospitals, deferred GI procedures are returning, and our workforce is starting to stabilize. We have anticipated this for some time in our strategy, operating efficiency and capital discipline, enable us to deliver attractive performance in this environment.

由於我們在第一季度的強勁表現，我們現在提高了全年指引，這表明我們對我們的運營充滿信心。在我們的業務中，大流行後的環境正在形成。 COVID 入院人數下降，更廣泛的敏銳度正在返回醫院，推遲的 GI 程序正在返回，我們的勞動力開始穩定下來。我們在我們的戰略、運營效率和資本紀律中已經預料到這一點，使我們能夠在這種環境下提供有吸引力的業績。

We had a great quarter at USPI with $340 million in adjusted EBITDA, which represents 21% growth over first quarter 2022. Same-facility cases grew 7.9% and adjusted EBITDA margins were strong at 37.6%. As I've said before, the continued migration of procedural services into the ambulatory setting is a sustained and significant tailwind for our business. Growth in our active physician population as well as higher acuity service line expansion, especially GI, urology, ENT and orthopedic cases drove the first quarter volume strength. We are pleased to have our organic growth initiatives gaining traction and bearing fruit.

我們在 USPI 有一個很棒的季度，調整後的 EBITDA 為 3.4 億美元，比 2022 年第一季度增長了 21%。同設施案例增長了 7.9%，調整後的 EBITDA 利潤率高達 37.6%。正如我之前所說，程序服務持續遷移到門診環境對我們的業務來說是一個持續而重要的順風。我們活躍的醫生人數的增長以及更高敏銳度的服務線擴張，尤其是胃腸道、泌尿科、耳鼻喉科和骨科病例推動了第一季度的銷量增長。我們很高興我們的有機增長計劃獲得牽引力並取得成果。

Our USPI development pipeline remains active and healthy. We added 3 new centers in the quarter, we completed 2 additional post-transaction buy-ups in the quarter at multiples unchanged from prior buy-ups. Progress continues in this area. As previously discussed, USPI's M&A engine under the Tenet umbrella is an industry-leading differentiator. We continue to drive post-synergy multiples for many of our acquisitions to below 5x. We intend to invest approximately $250 million in ambulatory M&A each year and have a robust pipeline to support that level of investment.

我們的 USPI 開發管道保持活躍和健康。我們在本季度增加了 3 個新中心，我們在本季度完成了 2 個額外的交易後收購，其倍數與之前的收購持平。這一領域繼續取得進展。如前所述，USPI 在 Tenet 保護傘下的併購引擎是行業領先的差異化因素。我們繼續將許多收購的協同效應後倍數降至 5 倍以下。我們打算每年投資約 2.5 億美元用於流動併購，並擁有強大的管道來支持這一水平的投資。

We are also energized by the level of de novo activity in the USPI pipeline with over 25 centers currently in syndication stages were under construction. USPI is the preferred partner for high-quality physicians as demonstrated by our organic growth and development pipeline. The linkage to our hospital business creates a superior platform of management talent and significant scale benefits.

我們也對 USPI 管道中的 de novo 活動水平感到鼓舞，目前有超過 25 個處於聯合階段的中心正在建設中。正如我們的有機增長和發展渠道所證明的那樣，USPI 是高素質醫生的首選合作夥伴。與我們醫院業務的聯繫創造了一個優秀的管理人才平台和顯著的規模效益。

Turning to our hospital segment. We generated $405 million of adjusted EBITDA in the first quarter of 2023. Same-store hospital adjusted admissions grew 6.7% and ER volumes grew 4.8% over the first quarter in 2022. On a non-COVID basis, same-store inpatient admissions were up 14%. Acuity levels remained strong as our case mix index has grown at a 3% compounded annual growth rate since 2019.

轉向我們的醫院部門。 2023 年第一季度，我們產生了 4.05 億美元的調整後 EBITDA。與 2022 年第一季度相比，同店醫院調整後入院人數增長了 6.7%，急診室數量增長了 4.8%。在非 COVID 的基礎上，同店住院病人入院人數增加了14%。自 2019 年以來，我們的案例組合指數以 3% 的複合年增長率增長，因此敏銳度水平保持強勁。

We continue to expand access to high acuity specialty services across our hospitals and enable access to cutting-edge clinical technologies. In the first quarter, we maintained our focus on cardiovascular, neurosciences, specialty surgical services, trauma and women's health. A few examples include a new noninvasive focused ultrasound technology to treat Alzheimer's patients at our Delray Medical Center. Certification of our Resolute Baptist Hospital as a Joint Commission Advanced primary stroke center and the achievement of a Level 1 trauma designation at our Desert Regional Medical Center, which enables us to provide total care for nearly every aspect of injury across a broad region of the Southwestern United States.

我們繼續擴大我們醫院獲得高敏度專業服務的機會，並使人們能夠獲得尖端的臨床技術。第一季度，我們繼續關注心血管、神經科學、專業外科服務、創傷和女性健康。幾個例子包括在我們的德爾雷醫療中心治療阿爾茨海默病患者的新型無創聚焦超聲技術。我們的 Resolute Baptist 醫院被認證為聯合委員會高級初級中風中心，並在我們的沙漠地區醫療中心獲得 1 級創傷指定，這使我們能夠為西南廣大地區幾乎所有方面的傷害提供全面護理美國。

Our workforce is getting stronger. Investments in 2022 and pay and benefits have reduced turnover and the pace of first quarter 2023 nurse hiring continues to accelerate. This helped to further reduce our contract labor costs in the first quarter of 2023. All in all, our hospitals have had a nice start to the year.

我們的員工隊伍越來越強大。 2022 年的投資以及薪酬和福利減少了營業額，2023 年第一季度護士招聘的步伐繼續加快。這有助於我們在 2023 年第一季度進一步降低合同工成本。總而言之，我們的醫院今年開局不錯。

Conifer continues to perform well for its clients and deliver strong margins. Ongoing technology automation and offshoring initiatives support that performance. Third-party revenue was up 3.8% in the quarter. And cash collection performance was strong in the quarter, helping to drive Tenet's days outstanding and accounts receivable down by 2 days from year-end. Conifer continues to ramp up commercial activities with a strong sales pipeline for 2023.

Conifer 繼續為其客戶表現良好，並提供可觀的利潤。持續的技術自動化和離岸計劃支持這種表現。本季度第三方收入增長 3.8%。本季度現金回款表現強勁，幫助推動 Tenet 的未償周轉天數和應收賬款天數較年底減少 2 天。 Conifer 繼續加強商業活動，並在 2023 年擁有強大的銷售渠道。

Looking forward, we are raising our full year '23 adjusted EBITDA guidance by $50 million at the midpoint to a range of $3.21 billion to $3.41 billion. Our management discipline, operational excellence and ongoing investments in talent have enabled a strong start to the year, and we remain focused on accelerating performance across our businesses.

展望未來，我們將在中點將 23 年全年調整後的 EBITDA 指引提高 5000 萬美元，達到 32.1 億美元至 34.1 億美元的範圍。我們的管理紀律、卓越運營和對人才的持續投資使今年開局良好，我們仍然專注於加快我們業務的績效。

At USPI, strong margins, organic growth tailwinds and inherent capital efficiencies generate significant free cash flow. Continuing to add centers with strong margins and attractive post-synergy multiples remains a great use of cash for investments to enhance Tenet's free cash flow. These cash flows will enable us to further grow, deleverage the balance sheet and return capital to shareholders in the future.

在 USPI，強勁的利潤率、有機增長的順風和固有的資本效率產生了可觀的自由現金流。繼續增加具有高利潤率和有吸引力的後協同倍數的中心仍然是現金投資的重要用途，以增強 Tenet 的自由現金流。這些現金流將使我們能夠在未來進一步發展、去槓桿化資產負債表並向股東返還資本。

And with that, Dan will provide a more detailed review of our financial results. Dan?

因此，Dan 將對我們的財務業績進行更詳細的審查。擔？

Thanks, Saum. And good morning, everyone. Our financial results in the first quarter were strong with our USPI and hospitals adjusted EBITDA and same-store volumes and revenues well above our expectations. In the quarter, we generated consolidated adjusted EBITDA of $832 million above the high end of our first quarter guidance range. Our results were driven by strong same-store revenues and volumes, continued high patient acuity for non-COVID patients and effective cost control.

謝謝，薩姆。大家早上好。我們第一季度的財務業績強勁，我們的 USPI 和醫院調整後的 EBITDA 以及同店銷量和收入遠高於我們的預期。本季度，我們產生的綜合調整後 EBITDA 為 8.32 億美元，高於我們第一季度指導範圍的上限。我們的業績是由強勁的同店收入和銷量、對非 COVID 患者的持續高敏銳度以及有效的成本控制推動的。

Now I'd like to highlight a few key items for each of our segments. Let's start with USPI, which delivered strong growth and continued to provide high-quality care to our patients. In the quarter, USPI produced a 7.9% increase in same-facility surgical cases compared to last year with strong growth in GI, urology, ENT and orthopedic cases. Surgical cases were 107% of prepandemic levels in the quarter. USPI's adjusted EBITDA grew 21% compared to the first quarter of '22, and its margins continue to be very strong at 37.6%. We are pleased with USPI's excellent start to the year. This strong performance is a testament to the attractiveness of the portfolio and value that we provide to our stakeholders.

現在我想強調我們每個細分市場的幾個關鍵項目。讓我們從 USPI 開始，它實現了強勁的增長並繼續為我們的患者提供高質量的護理。在本季度，與去年相比，USPI 的同設施手術病例增加了 7.9%，其中 GI、泌尿外科、耳鼻喉科和骨科病例增長強勁。本季度手術病例為大流行前水平的 107%。與 2022 年第一季度相比，USPI 調整後的 EBITDA 增長了 21%，其利潤率繼續非常強勁，達到 37.6%。我們對 USPI 今年的出色開局感到高興。這種強勁的表現證明了我們為利益相關者提供的投資組合和價值的吸引力。

Turning to our acute care hospital business. First quarter same-hospital adjusted admissions increased 6.7% compared to the first quarter of last year. In total, same-hospital inpatient admissions increased 4.3%, while non-COVID admissions increased 14%. Our labor management continues to be very effective despite the cost pressures, especially temporary contract nurse staffing costs. On a consolidated basis, contract labor costs were 6% of SW&B, a significant decline from 7.3% in the fourth quarter 2022.

轉向我們的急症護理醫院業務。第一季度同院調整後入院人數與去年第一季度相比增長了 6.7%。總體而言，同一醫院住院病人增加了 4.3%，而非 COVID 住院病人增加了 14%。儘管存在成本壓力，尤其是臨時合同護士人員成本，我們的勞動力管理仍然非常有效。在綜合基礎上，合同工成本佔 SW&B 的 6%，較 2022 年第四季度的 7.3% 大幅下降。

Total hospital costs were well managed in the quarter as these costs were 2.7% lower than first quarter 2022 on a per adjusted admission basis, when you exclude the impact in the prior year from a $69 million gain on sale of medical office buildings. SW&B costs per adjusted admission were down 5.4% compared to first quarter last year. Our SW&B costs as a percent of revenue were 45% in the quarter compared to 46% in the first quarter of '22 and 46.2% in fourth quarter of last year.

本季度醫院總成本得到了很好的管理，因為這些成本比 2022 年第一季度降低了 2.7%，按調整後的入院人數計算，如果您將上一年的影響從醫療辦公樓的銷售收益中排除，則為 6900 萬美元。與去年第一季度相比，每次調整後的 SW&B 成本下降了 5.4%。我們的 SW&B 成本佔收入的百分比在本季度為 45%，而 2022 年第一季度為 46%，去年第四季度為 46.2%。

Our case mix in revenue yield remains strong as we continue our strategic focus on investments in higher acuity, higher margin service lines. Our case mix index in the quarter has grown at a 3% CAGR since 2019 before the pandemic. Our hospital's first quarter results included $27 million of insurance proceeds received related to last year's cybersecurity incident. As we previously disclosed, our guidance reflected $10 million of these recoveries in the quarter, which were received in January.

隨著我們繼續將戰略重點放在對更高敏銳度、更高利潤率服務線的投資上，我們的收入收益案例組合仍然強勁。自 2019 年大流行之前以來，我們本季度的病例組合指數以 3% 的複合年增長率增長。我們醫院第一季度的業績包括與去年網絡安全事件相關的 2700 萬美元保險收益。正如我們之前披露的那樣，我們的指引反映了本季度 1 月份收到的 1000 萬美元的回收款。

As a reminder, in the first quarter of last year, we recorded a $69 million gain on the sale of medical office buildings as well as $31 million of Texas Medicaid revenue that related to 2021.

提醒一下，在去年第一季度，我們記錄了 6900 萬美元的醫療辦公樓銷售收益以及與 2021 年相關的德州醫療補助收入 3100 萬美元。

Let's now turn to Conifer, which again delivered a solid quarter. Conifer produced first quarter adjusted EBITDA of $87 million and a strong margin of approximately 27%. Also, Conifer generated 3.8% growth in revenue from external clients compared to the first quarter last year. Overall, we're off to a good start to the year in each of our businesses.

現在讓我們轉向 Conifer，它再次交付了一個穩定的季度。 Conifer 第一季度調整後的 EBITDA 為 8700 萬美元，利潤率高達約 27%。此外，與去年第一季度相比，Conifer 來自外部客戶的收入增長了 3.8%。總的來說，我們今年的每項業務都有一個良好的開端。

Now let's review our cash flows, balance sheet and capital structure. At the end of the quarter, we had $766 million of cash on hand and no borrowings outstanding under our $1.5 billion line of credit facility. We generated $214 million of free cash flow in the quarter. As a reminder, the first quarter is oftentimes our softest cash flow generating quarter due to certain annual working capital requirements, such as our annual 401(k) matching contributions for our employees and annual incentive compensation payments.

現在讓我們回顧一下我們的現金流、資產負債表和資本結構。在本季度末，我們手頭有 7.66 億美元的現金，並且在我們的 15 億美元信貸額度下沒有未償還的借款。我們在本季度產生了 2.14 億美元的自由現金流。提醒一下，由於某些年度營運資金要求，例如我們為員工提供的年度 401(k) 匹配供款和年度激勵薪酬支付，第一季度通常是我們產生現金流最疲軟的季度。

Conifer produced a strong cash collection performance in the first quarter, which resulted in a 2-day improvement in our days in AR. Also during the quarter, we repurchased approximately 906,000 shares of our stock for $50 million as part of our $1 billion share repurchase program. Since the inception of the program in the fourth quarter last year, we have repurchased approximately 6.8 million shares or about 6% of our then outstanding shares for $300 million at an average price of about $44 per share.

Conifer 在第一季度產生了強勁的現金回款表現，這導致我們的 AR 天數縮短了 2 天。同樣在本季度，作為我們價值 10 億美元的股票回購計劃的一部分，我們以 5000 萬美元的價格回購了大約 906,000 股股票。自去年第四季度該計劃啟動以來，我們以每股約 44 美元的平均價格，以 3 億美元的價格回購了約 680 萬股股票，約占我們當時已發行股票的 6%。

Our March 31 leverage ratio was 4.19x EBITDA, slightly up from 4.1x at year-end '22. And as a reminder, we have no significant debt maturities until the third quarter of 2024 and have approximately $1.6 billion of secured debt borrowing capacity available if needed.

我們 3 月 31 日的槓桿率為 4.19 倍 EBITDA，略高於 22 年底的 4.1 倍。提醒一下，我們在 2024 年第三季度之前沒有重大債務到期，如果需要，我們有大約 16 億美元的有擔保債務借貸能力。

Let me now turn to our outlook for this year. As Saum mentioned, we are raising our 2023 adjusted EBITDA outlook by $50 million to $3.21 billion to $3.41 billion or $3.310 billion at the midpoint, reflecting the strong start to the year. This $50 million increase includes a $20 million raise for USPI and a $30 million raise for our hospitals. Additionally, we now expect [non-operating] revenues to be in the range of $19.8 billion to $20.2 billion. Also, we expect full year adjusted diluted earnings per share from continuing operations to now be in the range of $4.92 to $6.09.

現在讓我談談我們對今年的展望。正如 Saum 所提到的，我們將 2023 年調整後的 EBITDA 前景上調 5000 萬美元至 32.1 億美元至 34.1 億美元或中點 33.10 億美元，反映出今年開局強勁。這 5,000 萬美元的增加包括為 USPI 增加的 2,000 萬美元和為我們的醫院增加的 3,000 萬美元。此外，我們現在預計 [非運營] 收入將在 198 億美元至 202 億美元之間。此外，我們預計全年調整後的持續經營攤薄每股收益目前在 4.92 美元至 6.09 美元之間。

Regarding our second quarter outlook, we expect consolidated adjusted EBITDA to be in the range of $765 million to $815 million. And we anticipate the USPI's EBITDA in the second quarter at the midpoint will be approximately 23% to 24% of our full year 2023 USPI EBITDA guidance of $1.465 billion at the midpoint of our range.

關於我們的第二季度展望，我們預計綜合調整後的 EBITDA 將在 7.65 億美元至 8.15 億美元之間。我們預計 USPI 第二季度的 EBITDA 中點將約為我們 2023 年全年 USPI EBITDA 指導值 14.65 億美元的中點值的 23% 至 24%。

Turning to our cash flows for 2023. From a cash flow perspective, we are targeting another strong year of free cash flow generation and now expect free cash flow in the range of $1.1 billion to $1.35 billion for 2023, an increase of $25 million over our previous expectations. Our free cash flow generation has improved substantially over the past several years. We have significantly reduced our leverage and pushed out debt maturities. And we expect our business to continue to drive strong cash flows while executing on our growth plans. As we have mentioned previously, these cash flows provide us with significant financial flexibility to effectively deploy capital for the benefit of shareholders.

談到我們 2023 年的現金流。從現金流的角度來看，我們的目標是又一個強勁的自由現金流產生年，現在預計 2023 年的自由現金流將在 11 億美元至 13.5 億美元之間，比我們的預期增加 2500 萬美元之前的期望。在過去的幾年裡，我們的自由現金流產生有了很大的改善。我們大幅降低了槓桿率並推遲了債務到期日。我們預計我們的業務將在執行增長計劃的同時繼續推動強勁的現金流。正如我們之前提到的，這些現金流為我們提供了顯著的財務靈活性，可以為股東的利益有效地配置資本。

As a reminder, our capital deployment priorities have not changed. First, we continued planning on allocating approximately $250 million of capital annually to grow our USPI surgery center business. Second, enhancing our hospital growth opportunities, including the continued focus on higher acuity service offerings. Third, evaluating further opportunities to retire and/or refinance debt. And finally, share repurchases, depending on market conditions and other investment opportunities.

提醒一下，我們的資本部署優先事項沒有改變。首先，我們繼續計劃每年分配約 2.5 億美元的資金來發展我們的 USPI 手術中心業務。其次，增加我們醫院的發展機會，包括繼續關注更高敏銳度的服務產品。第三，評估進一步的退休和/或再融資債務的機會。最後，股票回購，取決於市場狀況和其他投資機會。

And with that, we're ready to begin the Q&A. Operator?

這樣，我們就可以開始問答環節了。操作員？

(Operator Instructions) Our first question today is coming from Brian Tanquilut from Jefferies.

（操作員說明）我們今天的第一個問題來自 Jefferies 的 Brian Tanquilut。

Congrats on the good quarter. I guess my question is, just how much improvement do you think you have left to bring down temp labor? I know you're reinvesting some of that in wages for your permanent employees. But as we think about temp labor and maybe (inaudible) as a whole, what do you think is the remaining opportunity for that embedded in your guidance and even as we look into next year?

恭喜這個好季度。我想我的問題是，您認為您還有多少改進可以減少臨時工？我知道您正在將其中的一部分再投資於您的長期僱員的工資。但是，當我們考慮臨時工，也許（聽不清）作為一個整體時，您認為您的指導中所包含的剩餘機會是什麼，甚至在我們展望明年時也是如此？

Brian, it's Dan. We do expect some additional moderation in our contract labor spend as we move through the year. The operators have done a really phenomenal job managing this. It's obviously a very difficult environment. Our recruiting and retention measures have been improving, which is helping to mitigate some of the incremental costs associated with contract labor. So we are expecting some additional moderation as we move through the year. But as we've said when we released our guidance in February for this year, we are not expecting our contract labor to get back to pre-pandemic levels, certainly. That won't happen this year.

布賴恩，是丹。我們確實預計，隨著這一年的推移，我們的合同工支出會有所放緩。運營商在管理這方面做得非常出色。這顯然是一個非常困難的環境。我們的招聘和保留措施一直在改進，這有助於減輕與合同工相關的部分增量成本。因此，我們預計在這一年中會有一些額外的緩和。但正如我們在 2 月份發布今年的指導時所說的那樣，我們當然不會期望我們的合同工恢復到大流行前的水平。今年不會發生這種情況。

Our next question is coming from Pito Chickering from Deutsche Bank.

我們的下一個問題來自德意志銀行的 Pito Chickering。

A great quarter. For guidance, you beat the midpoint of the first quarter guidance by $57 million. You raised 2Q at $50 million above the [street] but only raised the full year by about $50 million. So just curious, should we read sort of into the implied back half of your guidance reduction this conservatism is something that the street was missing or simply did the street misunderstand the seasonality for the back half of the year or first half of the year?

一個偉大的季度。作為指導，您比第一季度指導的中點高出 5700 萬美元。你在第 2 季度籌集了比 [street] 高出 5000 萬美元的資金，但全年只籌集了大約 5000 萬美元。所以只是好奇，我們是否應該讀懂你的指導減少的隱含後半部分，這種保守主義是街道缺失的東西，或者只是街道誤解了今年下半年或上半年的季節性？

Peter, it's Dan. No, you shouldn't read into anything of that. Listen, we get off to a good start to the year. We beat by $57 million. And we've raised our guidance by $50 million. So we're optimistic, and we're encouraged by the trends that we've seen, and that shouldn't read anything into it.

彼得，是丹。不，你不應該閱讀其中的任何內容。聽著，我們今年開了個好頭。我們擊敗了 5700 萬美元。我們已經將我們的指引提高了 5000 萬美元。所以我們很樂觀，我們對我們所看到的趨勢感到鼓舞，這不應該對它產生任何影響。

Your next question is coming from Justin Lake from Wolfe Research.

您的下一個問題來自 Wolfe Research 的 Justin Lake。

This is Austin on for Justin. Really strong quarter on the volume side, both in USPI and the hospital. Just curious, you guys had kind of talked previously some service line flexing in the hospitals and then some COVID-driven interruptions in USPI. Were any of those still present in the 1Q here, or are we kind of at a clean comp going forward?

這是賈斯汀的奧斯汀。 USPI 和醫院的銷量方面都非常強勁。只是好奇，你們之前曾談到醫院的一些服務線彎曲，然後是 USPI 的一些 COVID 驅動的中斷。第一季度是否還有這些人，或者我們是否在一個乾淨的競爭中前進？

It's Saum. On the hospital side, as Dan was just talking about with the prior -- one of the prior questions, as the contract labor rates come down, and I indicated a little bit in my comments, it opens up the ability to improve access for services. The demand, we know the demand has been there. It's always been a bit about whether that demand at scale was serviceable with very high contract labor costs.

是薩姆。在醫院方面，正如 Dan 剛剛談到的先前問題 - 先前的問題之一，隨著合同工費率的下降，我在評論中提到了一點，它開闢了改善服務獲取的能力.需求，我們知道需求一直存在。一直以來，人們都在關注這種大規模需求是否可以在非常高的合同工成本下得到滿足。

And I think, in particular, as the contract labor rates come down, it makes it easier to make decisions about utilizing contract labor versus the full-time labor from the perspective of opening up that hospital capacity to take in more volume. And obviously, imperative in that is that we continue to have discipline in our overall cost structure, productivity, length of stay, things that we've talked about for the past few years during the pandemic, continuing to remain focused on that, so that we can generate strong margins as we open up the capacity even if some of the work that returns is lower acuity.

而且我認為，特別是隨著合同工率的下降，從開放醫院容量以接收更多容量的角度來看，更容易決定使用合同工還是全職勞動力。顯然，當務之急是我們繼續在我們的整體成本結構、生產力、停留時間以及我們在過去幾年大流行期間談論的事情上保持紀律，繼續關注這一點，以便即使一些返回的工作敏銳度較低，我們也可以在開放能力時產生可觀的利潤。

On the USPI side, I'm really pleased with the volume strength. This is not -- we've talked over the last couple 3 quarters about things that were going on in the business, certain types of low acuity business that we were strategically and otherwise having reductions in that affected it. This quarter demonstrated growth in the services that we want to grow, strong return of GI services, orthopedic strength was strong. And in particular, I've commented about pain before.

在 USPI 方面，我對成交量非常滿意。這不是——我們在過去的三個季度裡討論了業務中發生的事情，我們在戰略上進行的某些類型的低敏銳度業務，否則會減少影響它的業務。本季度顯示了我們想要增長的服務的增長，胃腸道服務的強勁回報，骨科實力強勁。特別是，我之前評論過疼痛。

The volume strength is not coming from pain. It's -- that business was flat year-over-year. So it's -- this isn't a volume recovery based upon kind of, so to speak, engineering certain service lines that we were dampening our interest in, but it is actual strength in many of the areas. And I think most importantly, breaking through significantly the prepandemic volume levels is a really important marker for USPI and the ASC industry, because it suggests that there will be strength going forward.

體積強度不是來自疼痛。這是 - 該業務同比持平。所以它 - 這不是基於某種可以說是設計我們正在抑制我們興趣的某些服務線的數量恢復，但它是許多領域的實際實力。而且我認為最重要的是，顯著突破大流行前的交易量水平對於 USPI 和 ASC 行業來說是一個非常重要的標誌，因為它表明未來將會有實力。

Thank you. Next question is coming from Calvin Sternick from JPMorgan.

謝謝。下一個問題來自摩根大通的 Calvin Sternick。

I wanted to ask about some of the [SCD 2] centers and how the integration is forcing there. I know you talked about slower physician bias last year and the ramping of some of the de novo and developing centers. So just curious how that's trended so far just to sort of understand some of the progress.

我想詢問一些 [SCD 2] 中心的情況，以及整合是如何迫使那裡進行的。我知道你去年談到了醫生偏見的減緩以及一些新的和發展中的中心的增加。所以只是好奇到目前為止的趨勢如何，只是為了了解一些進展。

Yes. No, good question, good update. As I indicated, the buy-ups continue, the progress in the buy-ups continue at multiples that are not changed from any of the prior multiples. So that's good. And the centers that were in development, as I kind of described them somewhere from the point of having broken ground to just having opened. We expect all of them from that original transaction #2 to be opened up this year, and that's a good thing. Those partnerships are still strong and intact. So I think we'll see positive movement. Like I said last -- we're about a year behind the original plan, but the original plan is still the original plan.

是的。不，好問題，好更新。正如我所指出的，收購仍在繼續，收購的進展繼續以與之前任何倍數都沒有變化的倍數進行。所以這很好。以及正在開發中的中心，正如我在某個地方描述的那樣，從破土動工到剛剛開業。我們預計來自原始交易 #2 的所有這些都將在今年開放，這是一件好事。這些夥伴關係仍然牢固且完好無損。所以我認為我們會看到積極的變化。就像我上次說的——我們比原計劃晚了大約一年，但原計劃仍然是原計劃。

Next question is coming from Kevin Fischbeck from Bank of America.

下一個問題來自美國銀行的 Kevin Fischbeck。

Just wanted to ask about your views about the volumes in the quarter. It sounds like the volumes were stronger than we were looking for, it sounds like maybe they were even stronger than you guys were looking for. Is there something that you would point to as to why all of a sudden 2023 is the beginning of this volume rebound? And just maybe to go back to that earlier question about the guidance because it is kind of -- you raised for the [beat]. It sounds like it's conservatism. But is there any reason to believe either based upon how volumes progressed through Q1 or so far in Q2 that these higher volume numbers wouldn't persist?

只是想問問您對本季度銷量的看法。聽起來音量比我們想要的要強，聽起來它們可能比你們想要的還要強。關於為什麼突然間 2023 年是這種成交量反彈的開始，您有什麼要指出的嗎？也許只是回到之前關於指南的問題，因為它有點——你提出來 [beat]。這聽起來像是保守主義。但是，是否有任何理由相信，根據第一季度的銷量進展情況或第二季度到目前為止的銷量，這些較高的銷量數字不會持續存在？

Yes. This is Saum. So a couple of things. I think the volume strength at this point, we really have our information and what we've read publicly about HCA's information. I think there is some industry recovery going on as we kind of enter this post-COVID -- post pandemic anyway, environment where people are getting more comfortable returning to health care. We know that from our physicians' offices, they're now all -- the ones that we employ and run are now all running at full throughput in the outpatient environment. Obviously, that helps to create demand.

是的。這是薩姆。所以有幾件事。我認為此時的音量強度，我們確實擁有我們的信息以及我們公開閱讀的有關 HCA 信息的內容。我認為，隨著我們進入這個後 COVID 時代，行業正在復蘇——無論如何，在大流行之後，人們越來越願意回到醫療保健的環境。我們從我們的醫生辦公室知道，他們現在都是——我們僱用和運營的醫生現在都在門診環境中全速運行。顯然，這有助於創造需求。

I think that we've, in our case, gotten much more effective and efficient with our ER throughput and operations across the board. That was a big focus area last year that we didn't talk much about, but with the staffing shortages, having adequate throughput, having fast track setups in our ERs and things to improve that throughput is important to be able to service the demand. And then for us, in particular, I think that as we get into this post-pandemic environment, hospitals are going to naturally be able to hold on to and deliver when they have put in the right infrastructure, doctors and technology for higher acuity services that don't have a substitute location to go to. And for us, that's an important piece of the recovery puzzle across the board.

我認為，在我們的案例中，我們的 ER 吞吐量和全面運營變得更加有效和高效。這是去年我們沒有談論太多的一個重點領域，但由於人員短缺，有足夠的吞吐量，在我們的 ER 中有快速通道設置以及提高吞吐量的事情對於滿足需求很重要。然後對我們來說，特別是，我認為，當我們進入大流行後環境時，醫院在為更高敏銳度的服務投入正確的基礎設施、醫生和技術後，自然能夠堅持並提供服務沒有替代地點可去。對我們來說，這是全面恢復難題的重要組成部分。

Look, the other thing from a Tenet portfolio perspective, as we indicated, our portfolio has a pretty broad range of exposure to markets that handled states, that handled COVID differently. And we always had a little bit more recovery to go in some of the states that were more locked down. And I'm pleased to see that we're seeing some volume strength in those markets as well.

從 Tenet 投資組合的角度看，另一件事，正如我們所指出的，我們的投資組合對處理狀態的市場有相當廣泛的敞口，以不同的方式處理 COVID。在一些更加封鎖的州，我們總是有更多的恢復時間。我很高興看到我們在這些市場也看到了一定的成交量。

At USPI, I think there's a couple of things. One is, we put a lot of focus and reengineered some of our processes, incentives as well as service line priorities in the third quarter of last year -- third quarter and fourth quarter of last year going into this year, to focus a bit more on some of the things that we wanted to grow rather than just some of the things that we were trying to optimize out as a low acuity service. And I think getting that balance right has helped create some momentum at USPI with respect to organic growth. And yes, there's really no reason that I see looking forward at this point that, that should change.

在 USPI，我認為有幾件事。一是，我們在去年第三季度投入了很多精力並重新設計了我們的一些流程、激勵措施和服務線優先級——從去年第三季度和第四季度進入今年，更加關注在我們想要發展的一些事情上，而不僅僅是我們試圖將其優化為低敏銳度服務的一些事情。我認為獲得這種平衡有助於 USPI 在有機增長方面創造一些動力。是的，我真的沒有理由認為在這一點上應該改變。

And I'll just add my commentary to the guidance. Look, we're pleased to have delivered a good quarter, and we're pleased to have raised our guidance at this point in time. We're optimistic about the future. And we'll revisit as we look forward, depending on what the results look like.

我只是將我的評論添加到指南中。看，我們很高興交付了一個好的季度，我們很高興在這個時間點提高了我們的指導。我們對未來持樂觀態度。我們將在展望未來時重新審視，具體取決於結果。

Your next question is coming from A.J. Rice from Credit Suisse.

你的下一個問題來自 A.J.來自瑞士信貸的大米。

I wanted to just ask about 2 other areas that have been touched on. As you've done your analysis on redeterminations, we're getting sort of different views as to -- as people roll off of Medicaid, get picked up on public exchanges or hopefully on the commercial roles, whether that's a neutral event for you guys or a positive? How have you factored that into guidance?

我只想問一下其他 2 個已被觸及的領域。當你對重新決定進行分析時，我們會得到一些不同的觀點——隨著人們退出醫療補助計劃，在公共交易所或希望在商業角色上被選中，這對你們來說是否是一個中立的事件還是陽性？您如何將其納入指導？

And then any update on your -- generally on your managed care contracting. I know this year, you got a little help. It seemed like from labor rates and labor pressures rather, is that following through in your discussions for '24? Do you think you'll get some help on the labor side there in rates for '24?

然後是關於您的任何更新——通常是關於您的管理式醫療合同。我知道今年，你得到了一點幫助。似乎更像是從勞動力率和勞動力壓力來看，這是否會在您對 24 世紀的討論中得到貫徹？你認為你會在 24 年的費率方面得到勞工方面的幫助嗎？

A.J., it's Dan. Let me try to address those. In terms of the Medicaid redetermination, I would say at this point, we haven't seen anything, any substantive impact from the redeterminations, which really just began. But I would tell you that we have Conifer in our hospitals. We have dedicated resources to address this as the redeterminations occur state by state. We have communications across the enterprise through all levels of Conifer in the hospitals. We're doing other types of communications like web page banners with links to state enrollment websites.

A.J.，是丹。讓我嘗試解決這些問題。就醫療補助計劃的重新確定而言，我現在要說的是，我們還沒有看到重新確定的任何實質性影響，這實際上才剛剛開始。但我會告訴你，我們醫院裡有針葉樹。我們有專門的資源來解決這個問題，因為重新確定是逐州進行的。我們通過醫院中各個級別的 Conifer 在整個企業內進行通信。我們正在做其他類型的通信，例如帶有州註冊網站鏈接的網頁橫幅。

We've been going through and revising our screening scripts and reenrollment questions, updating various resource documents, messaging at the registration point of entry and broader messaging campaigns across our facilities and also working with community members, non-Tenet community members on the community and working with them and tracking some of those statistics. So far, nothing significant, but we're -- I think we're on top of it, and we're monitoring it closely.

我們一直在研究和修改我們的篩選腳本和重新註冊問題，更新各種資源文件，在入口處的註冊點發送消息，在我們的設施中開展更廣泛的消息傳遞活動，並與社區成員、非 Tenet 社區成員合作，與他們合作並跟踪其中一些統計數據。到目前為止，沒有什麼重要的，但我們 - 我認為我們已經掌握了它，並且我們正在密切監視它。

In terms of your question in terms of the guidance for the year, as we said in February, we haven't assumed any significant upside or downside from the redeterminations. We think it's premature at this point. Obviously, the exchange enrollment statistics were very encouraging in terms of the growth. So some of the individuals who may transition off of Medicaid roles, you would expect that many of those would potentially reach out and try to obtain exchange coverage. But again, we haven't factored anything significant into our guidance this year.

正如我們在 2 月份所說，關於你今年的指導問題，我們沒有假設重新確定有任何重大的上行或下行。我們認為現在還為時過早。顯然，就增長而言，交流招生統計數據非常令人鼓舞。因此，一些可能從 Medicaid 角色過渡的人，你會期望其中許多人可能會伸出援手並嘗試獲得交換保險。但同樣，我們沒有在今年的指導中考慮任何重要因素。

In terms of the commercial contracting, I would say, it's consistent with our previous messages on this. We think we're very well positioned. From a contracting perspective, we're essentially 95% contracted this year and around 85% next year and even in '25, fair amount of our business is already contracted. And listen, the terms, we've been clear, it's not like we've been getting CPI type of increases in every contract negotiation, but what we have seen, obviously, the levels of inflation are top of mind. They always have been, but certainly more pronounced now. And the conversations obviously are being held with the plans. And I would say some of our recent negotiations, I would -- it's a little bit better than what maybe we historically would have negotiated.

在商業合同方面，我想說，這與我們之前就此發出的信息是一致的。我們認為我們的定位非常好。從簽約的角度來看，我們今年基本上簽約了 95%，明年簽約了 85% 左右，甚至在 25 年，我們的相當數量的業務已經簽約。聽著，條款，我們已經很清楚了，並不是說我們在每次合同談判中都得到了 CPI 類型的增長，但我們所看到的顯然是通貨膨脹水平。他們一直都是，但現在肯定更加明顯。很明顯，對話是按照計劃進行的。我會說我們最近的一些談判，我會 - 它比我們過去可能會談判的要好一點。

Your next question is coming from Josh Raskin from Nephron Research.

您的下一個問題來自 Nephron Research 的 Josh Raskin。

Just wanted to get back to USPI in that 9% plus same-store revenue growth number. I was wondering if you could give some more color on maybe perhaps geographies and whether these were legacy centers or some of the newer ones that are ramping up? And then did you give a number for the buy-ups for the second SCB transaction?

只是想回到 USPI 9% 以上的同店收入增長數字。我想知道您是否可以在可能的地理位置上提供更多顏色，以及這些是傳統中心還是一些正在崛起的新中心？然後，您是否提供了第二筆 SCB 交易的購買數量？

And then lastly, I hate to keep harping on this guidance, but the guidance for USPI specifically sort of implies a lower growth rate for EBITDA over the next 3 quarters than what you saw in the first quarter. Any changes to seasonality? Anything you think about that or just sort of consistent with the overall message on guidance?

最後，我不想一直喋喋不休地談論這個指導，但 USPI 的指導特別暗示未來 3 個季度 EBITDA 的增長率低於你在第一季度看到的增長率。季節性有什麼變化嗎？您對此有何看法，或者只是與有關指導的總體信息保持一致？

Josh, it's Dan. Let me start. Now in terms of the guidance, we -- obviously, USPI is off to a great start to the year. We increased the guidance $20 million for EBITDA, strong volumes. We also increased our volume guidance assumptions from 2% to 3% to 3% to 4%. So we're obviously encouraged. Again, as I mentioned to another question, there's nothing to read into this. It's early in the year, and we like what we're seeing. And we'll continue to obviously reevaluate where things staying at the end of the second quarter and make any guidance changes, if appropriate. At that point in time, the (inaudible) business continues to generate incredible margins. So we're very pleased with the start to the year.

喬希，是丹。讓我開始吧。現在就指導而言，我們 - 顯然，USPI 今年開局不錯。我們將 EBITDA 的指導值增加了 2000 萬美元，銷量強勁。我們還將我們的銷量指導假設從 2% 提高到 3% 到 3% 到 4%。所以我們顯然受到鼓舞。同樣，正如我在另一個問題中提到的，沒有什麼可解讀的。今年年初，我們喜歡我們所看到的。顯然，我們將繼續重新評估第二季度末的情況，並在適當時做出任何指導變更。在那個時候，（聽不清）業務繼續產生令人難以置信的利潤。所以我們對今年的開始感到非常滿意。

Next question is coming from Ann Hynes from Mizuho Securities.

下一個問題來自瑞穗證券的 Ann Hynes。

I just want to talk about the No Surprise Billing Act. Is that having a negative impact on surgery volume at USPI? Some data that I've seen and checked suggests that maybe anesthesiologists aren't making as much money, so they're gravitating more towards inpatient or outpatient departments given the reimbursement is higher. So I guess is this having an impact? And if so, what do you think it is in the (inaudible) volumes?

我只想談談《無意外計費法》。這對 USPI 的手術量有負面影響嗎？我看過和檢查過的一些數據表明，麻醉師可能賺不到那麼多錢，所以他們更傾向於住院或門診，因為報銷更高。所以我想這會產生影響嗎？如果是這樣，您認為它在（聽不清）卷中是什麼？

Just a couple of comments there. I'm not sure that -- I'm not sure I could credibly answer that question with data. It's an interesting question, and something that we'll look into to see if we can identify any trends there. But what I would say is that the pressures that we've talked about before in the staffing arena for hospital-based or ASC-based physicians, in particular, in anesthesia is certainly an area that's requiring a lot of work. I mean your commentary about the activity and revenue intensity for anesthesiologists and hospitals versus ASCs is certainly true.

那裡只有幾條評論。我不確定——我不確定我能否用數據可靠地回答這個問題。這是一個有趣的問題，也是我們將研究的問題，看看我們是否可以確定其中的任何趨勢。但我要說的是，我們之前在醫院或 ASC 醫生的人員配置領域談到的壓力，特別是在麻醉方面，肯定是一個需要大量工作的領域。我的意思是你關於麻醉師和醫院與 ASC 的活動和收入強度的評論肯定是正確的。

But again, remember, our payer mix in the ASCs is significantly better. And that creates a draw to the ASC environment, in particular, in our ASCs the way they're set up. So while there's some pressure there, we're managing through it. And again, I would have to say that we'd have to take a look at the data more carefully to answer your question in any kind of statistically relevant manner. But it hasn't bubbled up as a major driver of the volume issues that we saw in particular, last year in the third quarter.

但請再次記住，我們在 ASC 中的付款人組合要好得多。這對 ASC 環境產生了吸引力，特別是在我們的 ASC 中，它們的設置方式。因此，儘管那裡存在一些壓力，但我們正在設法應對。再一次，我不得不說我們必須更仔細地查看數據，以任何一種統計相關的方式回答你的問題。但它並沒有成為我們去年第三季度特別看到的數量問題的主要驅動因素。

All right. Perfect. And then, Dan, I know (inaudible) free cash flow guidance, which is good. And can you remind us, do you have any share repurchase or incremental debt repayment and guidance at this point?

好的。完美的。然後，丹，我知道（聽不清）自由現金流指導，這很好。您能否提醒我們，此時您是否有任何股票回購或增量債務償還和指導？

No. No additional share repurchases are assumed in the guidance. And that was consistent with how we started the year with our guidance.

否。指引中沒有假設額外的股份回購。這與我們在指導下開始這一年的方式是一致的。

Your next question is coming from John Ransom from Raymond James.

你的下一個問題來自 Raymond James 的 John Ransom。

Kind of an in-the-weeds question, because all the good ones have been asked. If we look at kind of the rest of the year on USPI and you look specifically at revenue per procedure, what's going on there in terms of rate versus just mix? I mean we assume there's some natural lift as you get more ortho and less pain. But if you could kind of help us understand what's going on in that line item, that would be great.

有點雜草叢生的問題，因為所有好的問題都被問到了。如果我們看一下 USPI 今年剩餘時間的情況，並且您具體看一下每個程序的收入，那麼在比率和混合方面發生了什麼？我的意思是，我們假設隨著您獲得更多的矯形效果和更少的疼痛，自然會有一些提升。但是，如果您能幫助我們了解該訂單項中發生的情況，那就太好了。

Yes. No, John, I appreciate it. And that is still a good question, so I appreciate it. Listen, I think there's a couple of things. As I indicated -- and I think we've talked about this a bit before, but maybe not specifically. There are certain areas of health care services that were deferred or more actively deferred. And I think in our ASC business, in particular, we saw dampened utilization of procedures that might have preventative value and, in particular, in the Medicare population.

是的。不，約翰，我很感激。這仍然是一個很好的問題，所以我很感激。聽著，我認為有幾件事。正如我所指出的——我認為我們之前已經討論過這個問題，但可能不是特別具體。某些醫療保健服務領域被推遲或更積極地推遲。我認為，特別是在我們的 ASC 業務中，我們看到可能具有預防價值的程序的使用受到抑制，特別是在醫療保險人群中。

For us, in general, that's a good sign that it's coming back even if there's some impact on the net revenue per case. Because ultimately, as the ASCs become fuller, we'll get benefit from capacity utilization. And we had prepared for this a bit. We weren't sure when it was going to come back, to be honest, but we had prepared for this a bit by looking like we would in an acute care hospital environment for efficiencies within our ASCs that would help to maintain our margins. So we've been focused on knowing that this business is going to come back, knowing that some of the mix would be a little bit more challenging and doing the preparatory work to ensure that we maintain our margins by finding efficiencies in advance of it coming back. And it happened to come back a bit this quarter. And I think, again, I think that's a good sign.

對我們來說，總的來說，這是一個好兆頭，即使對每個案例的淨收入有一些影響，它也會回來。因為最終，隨著 ASC 變得更滿，我們將從產能利用率中獲益。我們為此做了一些準備。老實說，我們不確定它什麼時候會回來，但我們已經為此做了一些準備，看起來我們會在急症護理醫院環境中提高 ASC 的效率，這將有助於維持我們的利潤率。因此，我們一直專注於了解這項業務將會回歸，知道其中一些組合會更具挑戰性，並做好準備工作以確保我們通過在它到來之前提高效率來維持我們的利潤率後退。它恰好在本季度有所回升。我認為，我認為這是一個好兆頭。

Our independent physician partners' offices running at full throughput, similar to what we're seeing with our employed physician practices, if that happens across the board, I think that will be a nice tailwind. It will give them the confidence sometime this year to maybe recruit new partners to their practice and continue to grow their own businesses, which, again, will represent some long-term tailwind in our partnerships with them at USPI. So I think this is a good cycle to be in. Even if some of the mix and other things in the short term will be a bit more challenging. We'll stay focused on the margin performance.

我們獨立的醫生合作夥伴的辦公室以全吞吐量運行，類似於我們在我們僱傭的醫生實踐中看到的情況，如果這種情況全面發生，我認為這將是一個很好的順風。這將使他們有信心在今年的某個時候招募新的合作夥伴加入他們的實踐並繼續發展自己的業務，這將再次代表我們在 USPI 與他們的合作夥伴關係中的一些長期順風。所以我認為這是一個很好的周期。即使短期內的一些組合和其他事情會更具挑戰性。我們將繼續關注利潤率表現。

I take from that as a big colonoscopy quarter. That's what I'm hearing from you. Is that any way to think about it?

我認為這是一個很大的結腸鏡檢查季度。這就是我從你那裡聽到的。有什麼辦法可以考慮嗎？

Your next question is coming from Sarah James from Cantor Fitzgerald.

您的下一個問題來自 Cantor Fitzgerald 的 Sarah James。

I was hoping you could walk us through how you think about margin evolving as we start to come out of off of the peak of labor shortage. So how much margin leverage can you really get from scale as you're able to staff up? And then how do you think about some of the payer rate increases possibly falling through to margins?

當我們開始走出勞動力短缺的高峰期時，我希望你能告訴我們你如何看待利潤率的變化。那麼，隨著員工人數的增加，您真正可以從規模中獲得多少利潤率？然後你如何看待一些支付利率的增加可能會下降到利潤率？

Sarah, it's Dan. Listen, obviously, we've strengthened our margin significantly over the past several years, not only through USPI, but the hospital margins as well, and we're very mindful of that. And as additional volumes are treated and cared for given the efficiency of our hospital platform, we think there's opportunities for margin expansion. And obviously, the USPI's margins are phenomenal anywhere depending on the quarter from the high 30s to 40% territory.

莎拉，是丹。聽著，顯然，在過去幾年中，我們不僅通過 USPI，而且通過醫院利潤率顯著提高了我們的利潤率，我們非常注意這一點。考慮到我們醫院平台的效率，隨著額外的數量得到治療和照顧，我們認為有機會擴大利潤率。顯然，根據季度的不同，USPI 的利潤率從 30% 到 40% 的高位不等。

But yes, certainly, adding additional volumes can help in terms of given at least on the hospital side, there are certain fixed costs. And so we can take on additional volumes and be profitable with and have a nice margin associated with it. The operators' very -- they've done really just a phenomenal job during the past several years and driving efficiencies in incredibly highly inflationary and challenging environment. And you see it in our cost statistics, clearly.

但是，是的，當然，至少在醫院方面，增加額外的數量會有幫助，有一定的固定成本。因此，我們可以承擔更多的業務量並從中獲利並獲得可觀的利潤。運營商非常 - 他們在過去幾年中確實做得非常出色，並在令人難以置信的高通脹和充滿挑戰的環境中提高了效率。您可以在我們的成本統計數據中清楚地看到它。

In terms of commercial pricing, as I mentioned earlier, we feel very good where we're at from a contracting perspective. And more recent negotiations, we've been able to negotiate rates with annual escalators that are a little bit higher than historically we may have negotiated. So we feel good about where we're at from a contracting perspective.

在商業定價方面，正如我之前提到的，從合同的角度來看，我們感覺非常好。在最近的談判中，我們已經能夠與年度自動扶梯協商利率，這比我們過去可能談判過的要高一點。因此，從合同的角度來看，我們對自己所處的位置感到滿意。

Your next question is coming from Ben Hendrix from RBC Capital Markets.

你的下一個問題來自 RBC 資本市場的 Ben Hendrix。

Certainly, appreciate the sequential color on improvement in agency costs and SW&B, but could you talk a little bit about how that impacted inpatient capacity constraints specifically? Your peer HCA noted a decline in rate of admission declines as percentage of inpatient volume. And I hope if you can give us an idea of how that has trended for the acute segment and how you see that progressing this year given your labor strategy.

當然，欣賞代理成本和 SW&B 改善的連續顏色，但你能談談這對住院容量限制的具體影響嗎？您的同行 HCA 注意到入院率下降佔住院人數的百分比。我希望你能告訴我們急性部分的趨勢如何，以及你如何看待今年根據你的分娩策略取得的進展。

This is Saum. I mean, I think probably, as I indicated before, I think probably the most important marker that we look at is the contract labor rate. I mean, we're building up our workforce. We've been focused on that for over a year. It has been slow going. It's improving quarter-over-quarter-over-quarter, which is a good thing in terms of recruiting and retention. But ultimately, the structural shortages in the market from a labor perspective haven't just disappeared as we move from '22 to '23. And so contract labor is still an important resource.

這是薩姆。我的意思是，我認為可能，正如我之前指出的那樣，我認為我們關注的最重要的指標可能是合同工率。我的意思是，我們正在建設我們的員工隊伍。一年多來，我們一直專注於此。進展緩慢。它正在逐季改善，這在招聘和保留方面是一件好事。但最終，隨著我們從 22 歲到 23 歲，從勞動力角度來看，市場結構性短缺並沒有消失。因此，合同工仍然是一種重要的資源。

But as those contract labor rates begin to normalize, you can use that contract labor more freely to open up capacity. For us, the math equation, if you will, on where we open up capacity and how, varies a bit because our markets are in different stages of recovery, different kind of cost structures, even different contract labor rates that we face in different markets. And so we kind of take that market by market. I think part of the volume strength that you saw in Q1 reflected the fact that we, as we indicated, opened up access to some of our services a bit more than we had in the past.

但隨著這些合同工費率開始正常化，你可以更自由地使用合同工來擴大產能。對我們來說，如果你願意的話，關於我們在哪裡開放產能以及如何開放產能的數學方程式會有所不同，因為我們的市場處於不同的複蘇階段，不同類型的成本結構，甚至我們在不同市場面臨的不同合同工費率.因此，我們有點逐個市場。我認為您在第一季度看到的部分數量強度反映了一個事實，正如我們所指出的那樣，我們比過去更多地開放了對我們某些服務的訪問。

And that's good, because it's not only testing whether the demand is there, but it's also our ability to service it at healthy margins. And that ended up being a good test for this quarter. And so we'll keep pushing on that. But we are also very focused on trying to drive contract labor unit rates back towards prepandemic levels. And though they won't get all the way there, perhaps, we're driving in that direction this year.

這很好，因為它不僅在測試需求是否存在，而且還在測試我們以健康的利潤率提供服務的能力。這最終成為本季度的一個很好的測試。因此，我們將繼續推動這一點。但我們也非常專注於努力將合同工單位費率推回到大流行前的水平。雖然他們不會一路走到那裡，但也許，我們今年正朝著這個方向前進。

Your next question is coming from Andrew Mok from UBS.

你的下一個問題來自瑞銀的 Andrew Mok。

Adjusted admits were up 6.7% in the quarter and outpatient -- inpatient admissions by about 240 basis points. Can you help us understand what's driving that spread? There weren't any obvious drivers in the outpatient stats that would blend adjusted admits higher.

本季度調整後的入院人數增加了 6.7%，門診入院人數增加了約 240 個基點。你能幫助我們了解是什麼推動了這種傳播嗎？門診統計數據中沒有任何明顯的驅動因素可以使調整後的錄取率更高。

Yes. Andrew, it's Dan. It's just a mix of the intensity of the outpatient volume and the gross revenue in relation to the inpatient side, that's the primary driver there. Obviously, our volumes' strength in the quarter was very strong. We're pleased with what we saw. And it was consistent throughout the quarter, which was encouraging, too.

是的。安德魯，是丹。這只是門診量的強度和與住院方面相關的總收入的混合，這是那裡的主要驅動力。顯然，我們本季度的銷量非常強勁。我們對我們所看到的很滿意。而且整個季度都保持一致，這也令人鼓舞。

Got it. So mix and acuity on the outpatient side was a driver of the strength there.

知道了。因此門診方面的混合和敏銳度是那裡力量的驅動力。

Yes, that's a contributor to -- and as I said, it was encouraging, not only on the hospital side, but also on the USPI side, the volumes were, generally speaking, strong throughout the quarter.

是的，這是一個貢獻——正如我所說，這是令人鼓舞的，不僅在醫院方面，而且在 USPI 方面，總的來說，整個季度的銷量都很強勁。

Next question today is coming from Jason Cassorla from Citigroup.

今天的下一個問題來自花旗集團的 Jason Cassorla。

Great. Just wanted to ask about uncompensated care trends. It looks like bad debt in the quarter was up pretty decently year-over-year. That could be a comp issue, but any color on what drove that bad debt expense higher? And just overall on compensated care up, call it, 12% year-over-year in 1Q. I think that uncompensated care stat was up about 10% back in fourth quarter, too. So just any color on uncompensated care trends would be helpful.

偉大的。只是想問一下無償護理的趨勢。看起來本季度的壞賬同比增長相當可觀。這可能是一個薪酬問題，但究竟是什麼推動了壞賬費用的上升？總體而言，第一季度的補償護理同比增長 12%。我認為無償醫療統計數據在第四季度也增長了約 10%。因此，無償護理趨勢的任何顏色都會有所幫助。

Yes. Jason, it's Dan. Listen, I would say the year-over-year comp is probably more last year in seeing some lower levels. I would tell you the -- overall, the uncompensated care, we think it's been manageable. We've spent a lot of time with our Conifer team and hospital resources, doing everything possible for when someone who does not have an insurance, we assist them. And we do an incredible job of finding other forms of insurance through our eligibility enrollment program. So yes, it's -- I wouldn't say we're never concerned about uncompensated care, but the trends are essentially in line with what our expectations are so far this year.

是的。傑森，是丹。聽著，我想說去年的同比比較可能更多，因為看到了一些較低的水平。我會告訴你——總的來說，無償護理，我們認為這是可以控制的。我們花了很多時間與我們的針葉樹團隊和醫院資源一起，盡一切可能為沒有保險的人提供幫助。通過我們的資格註冊計劃，我們在尋找其他形式的保險方面做得非常出色。所以是的，我不會說我們從不擔心無償護理，但趨勢基本上符合我們今年迄今為止的預期。

Our final question today is coming from Stephen Baxter from Wells Fargo.

我們今天的最後一個問題來自 Wells Fargo 的 Stephen Baxter。

I want to ask another one on the ambulatory side. It's a little bit of a longer-term question. I was hoping you could talk a little bit more about the outlook for ortho procedure growth and the opportunity here over the next couple of years. We've had this massive shift of ortho procedures in the inpatient hospital set into the outpatient hospital setting compared to where we're pre-COVID. I guess for the ASCs, do you think about the ship as having pulled forward the opportunity there in a meaningful way?

我想問門診那邊的另一個。這是一個比較長期的問題。我希望你能多談談未來幾年矯形手術發展的前景和這裡的機會。與我們在 COVID 之前的地方相比，我們已經將住院醫院的矯正程序大規模轉變為門診醫院環境。我想對於 ASC，您是否認為這艘船以有意義的方式推動了那裡的機會？

And then second, what do you need to do strategically to help migrate these procedures into your ASCs?

其次，您需要從戰略上做些什麼來幫助將這些程序遷移到您的 ASC 中？

Yes, it's Saum. I mean I think -- a couple of things. I mean, first of all, you're right that a lot of what used to be done inpatient with a multi-day stay. Even if it's a short stay, it's turning into hospital-based outpatient surgery. And I would say, the moment you have something that turns into hospital-based outpatient surgery, there's going to be a subset of patients that will qualify in an ambulatory surgery setting.

是的，是薩姆。我的意思是我認為 - 有幾件事。我的意思是，首先，你是對的，很多過去都是在住院多日的情況下完成的。即使是短暫停留，也正在轉變為以醫院為基礎的門診手術。我想說的是，一旦你有一些東西變成了基於醫院的門診手術，就會有一部分患者符合門診手術的條件。

Over time, it will be more of the comorbidities that patients have that determine the site of care rather than the technical nature of the potential procedure and what that recovery will look like from the standpoint of being able to ambulate and get home on a same-day basis. And so that's really I think what will end up determining what the ultimate mix of inpatient hospital-based outpatient, especially when there's certain comorbidities that one needs to be careful with versus a fully ambulatory ASC outpatient setting.

隨著時間的推移，更多的是患者的合併症決定了護理地點，而不是潛在手術的技術性質，以及從能夠走動和回家的角度來看，恢復會是什麼樣子-日基礎。因此，我認為這真的是什麼最終會決定住院病人和門診病人的最終組合，特別是當有某些合併症需要小心，而不是完全門診的 ASC 門診病人時。

I would tell you that our belief in the ASC setting in this area for much more runway comes from the fact that we continue to see growth in the ASC setting. We continue to see new patients, including Medicare senior patients that are older being effectively treated in the ASC setting, along with expanding the commercial market. And we continue to see physicians coming to USPI, wanting to initiate their first orthopedics de novo work in our centers, either through new center development or joining existing centers. So I think there's still demand and runway to go for ASC-based orthopedics.

我會告訴你，我們相信 ASC 設置會在這個區域有更多的跑道，這是因為我們繼續看到 ASC 設置的增長。我們繼續看到新患者，包括年齡較大的 Medicare 老年患者在 ASC 環境中得到有效治療，同時擴大商業市場。我們繼續看到醫生來到 USPI，希望通過新中心開發或加入現有中心，在我們的中心開始他們的第一個骨科從頭工作。所以我認為基於 ASC 的骨科仍然有需求和跑道。

Longer term, what we're focused on is looking at areas within orthopedics or even spine work that today are very much done in the acute care hospital and developing clinical algorithms to figure out how to safely do those types of procedures more actively in the ASC setting. So in orthopedics, an example of that would be shoulder surgery and as I indicated, spine surgery. And I think we'll see a migration in those areas in a few years as well.

從長遠來看，我們關注的重點是研究骨科甚至脊柱工作中的領域，這些領域目前在急症護理醫院進行了大量工作，並開發臨床算法以弄清楚如何在 ASC 中更積極地安全地進行這些類型的手術環境。因此，在整形外科中，肩部手術就是一個例子，正如我所指出的，脊柱手術。我認為我們也會在幾年內看到這些地區的遷移。

Thank you. We reach the end of our question-and-answer session. And ladies and gentlemen, that does conclude today's teleconference and webcast. You may disconnect your lines at this time. And have a wonderful day. We thank you for your participation today.

謝謝。我們的問答環節結束了。女士們，先生們，今天的電話會議和網絡廣播到此結束。此時您可以斷開線路。祝你有美好的一天。感謝您今天的參與。