Tenet Healthcare Corp (THC) 2023 Q2 法說會逐字稿

Greetings, and welcome to the Tenet Healthcare Second Quarter 2023 Earnings Conference Call and Webcast. After the speaker remarks, there will be a question-and-answer session for industry analysts (Operator Instructions).

您好，歡迎參加 Tenet Healthcare 2023 年第二季度收益電話會議和網絡廣播。演講者發言後，將舉行行業分析師問答環節（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.

現在我將把電話轉給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 afternoon, 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 second quarter 2023 results as well as a discussion of our financial outlook. Tenet's 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.

大家下午好，感謝您參加今天的電話會議。我是投資者關係副總裁威爾·麥克道爾。我們很高興您與我們一起討論 Tenet 2023 年第二季度的業績以及我們的財務前景。參加今天電話會議的 Tenet 高級管理層包括首席執行官 Saum Sutaria 博士；執行副總裁兼首席財務官 Dan Cancelmi。

Our webcast this afternoon includes a slide presentation, which has been posted to the Investor Relations section of our website, tenethealth.com. 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.

今天下午我們的網絡廣播包括幻燈片演示，該演示已發佈到我們網站 tenethealth.com 的投資者關係部分。本次電話會議的聽眾請注意，我們今天討論中所做的某些陳述具有前瞻性，代表了管理層根據當前可用信息做出的預期。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示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.

這樣，我就把電話轉給 Saum。

Thank you, Will, and good afternoon, everyone. Before we get into this quarter's results, I'd like to start by extending a warm welcome to Sun Park, who has joined us for this phone call. Sun will become our Chief Financial Officer following Dan's retirement. He has more than 25 years of finance experience and an impressive track record of delivering positive results in the health care industry. Most recently, he was responsible for the commercial and operational finance for all of AmerisourceBergen's business units. The CFO transition of Tenet is actively underway, supported by our broader leadership team. I look forward to the impact of Sun's leadership as we continue to execute on our strategic priorities.

謝謝威爾，大家下午好。在我們討論本季度的業績之前，我首先要對 Sun Park 加入我們的電話會議表示熱烈歡迎。 Dan 退休後，Sun 將成為我們的首席財務官。他擁有超過 25 年的財務經驗，並在醫療保健行業取得了積極成果，取得了令人印象深刻的業績記錄。最近，他負責 AmerisourceBergen 所有業務部門的商業和運營財務。在我們更廣泛的領導團隊的支持下，Tenet 首席財務官的過渡正在積極進行中。我期待著 Sun 的領導力在我們繼續執行我們的戰略重點時所產生的影響。

Now let's turn our attention to the results that I'm pleased to present for the second quarter. In the second quarter, we reported net operating revenues of $5.1 billion and consolidated adjusted EBITDA of $843 million, which translates into an attractive 16.6% margin. Robust volumes and effective cost control drove attractive results and strong free cash flows, and our adjusted EBITDA is about $53 million or 6.7% better than the midpoint of our guidance range.

現在讓我們將注意力轉向我很高興介紹的第二季度的結果。第二季度，我們報告淨營業收入為 51 億美元，綜合調整後 EBITDA 為 8.43 億美元，利潤率為 16.6%，極具吸引力。強勁的銷量和有效的成本控制推動了有吸引力的業績和強勁的自由現金流，我們調整後的 EBITDA 約為 5300 萬美元，比我們指導範圍的中值高出 6.7%。

We produced another very strong quarter in USPI, with $370 million of adjusted EBITDA, which represents 16% growth over second quarter 2022. Same-facility cases grew 6.6% and adjusted EBITDA margins remained robust. Orthopedics volumes were strong, with total joint replacements in the ASCs, up over 12% and over second quarter 2022, coupled with ongoing strength in GI, Urology and ENT. Net revenue per case improved nearly 3%.

我們的 USPI 又實現了非常強勁的季度，調整後 EBITDA 達到 3.7 億美元，比 2022 年第二季度增長 16%。同一設施案例增長 6.6%，調整後 EBITDA 利潤率依然強勁。骨科銷量強勁，2022 年第二季度，ASC 的關節置換總數增長了 12% 以上，再加上胃腸道、泌尿科和耳鼻喉科的持續增長。每個案例的淨收入提高了近 3%。

Looking ahead, the tailwinds that support ambulatory surgery demand recovery and growth are evident in the current environment. These tailwinds include an active but aging population, patients proactively seeking more convenient access to procedural care, a recovering health care ecosystem looking for lower sites of care and ongoing innovation in ambulatory surgery care delivery. These factors collectively create a strong foundation for continued growth.

展望未來，在當前環境下，支持門診手術需求恢復和增長的有利因素顯而易見。這些有利因素包括活躍但老齡化的人口、積極尋求更方便的程序護理的患者、正在恢復的醫療保健生態系統尋求較低的護理地點以及門診手術護理服務的持續創新。這些因素共同為持續增長奠定了堅實的基礎。

As the leader in this space, USPI is well positioned to capitalize on these opportunities. We continue to attract and retain high-quality positions, which has translated into growth in overall physicians performing procedural care in a USPI facility. We continue to expand high acuity service lines while delivering high patient and physician satisfaction through operational excellence. This has enabled strong volume growth from servicing new physicians as well as deferred demand.

作為該領域的領導者，USPI 完全有能力利用這些機會。我們繼續吸引並保留高質量的職位，這已轉化為在 USPI 機構中執行程序護理的醫生總數的增長。我們繼續擴大高敏銳度服務線，同時通過卓越的運營為患者和醫生提供高滿意度。這使得為新醫生提供服務以及延遲需求帶來了強勁的增長。

It is worth noting that GI case growth has been particularly strong so far this year. We see evidence of both deferred care and also expansion of care for the under 50-year-old patient population from recent guideline changes, which we believe should be a source of ongoing and expanding demand over time. During the quarter, we successfully expanded our reach by adding 12 new centers. Among this impressive new portfolio are 3 single specialty GI centers in Ohio, bringing our total to 12 in the state. Additionally, 2 of our new facility openings were focused on orthopedics and de novos in Michigan and Florida.

值得注意的是，今年迄今為止，地理標誌案件增長尤其強勁。我們從最近的指南變化中看到了延遲護理和擴大對 50 歲以下患者群體的護理的證據，我們認為隨著時間的推移，這應該是持續和不斷擴大的需求的來源。本季度，我們通過增加 12 個新中心成功擴大了業務範圍。在這個令人印象深刻的新產品組合中，有 3 個位於俄亥俄州的單一專業 GI 中心，使該州的總數達到 12 個。此外，我們在密歇根州和佛羅里達州開設的 2 個新設施專注於骨科和從頭手術。

We are also encouraged by the high level of de novo activity in our pipeline, with more than 30 centers currently in the syndication stages or under construction. This demonstrates momentum in our expansion efforts and further strengthens our growth prospects. USPI's future is bright, and our capital deployment into this business will continue to grow and develop this portfolio.

我們還對我們管道中的高水平從頭活動感到鼓舞，目前有 30 多個中心處於聯合階段或正在建設中。這表明了我們擴張努力的勢頭，並進一步增強了我們的增長前景。 USPI 的未來是光明的，我們對該業務的資本部署將繼續增長和發展該投資組合。

Turning to our hospital segment. We generated $388 million of adjusted EBITDA in second quarter 2023. Acuity remained strong, with revenue per adjusted admission up 4% over second quarter 2022. On a non-COVID basis, same-store admissions were up 5%. Our workforce continues to grow and stabilize. We have successfully reduced turnover, and nurse hiring has accelerated and showed improvement.

轉向我們的醫院部門。 2023 年第二季度，我們實現了3.88 億美元的調整後EBITDA。Acuity 依然強勁，調整後的每次入場收入比2022 年第二季度增長了4%。在非新冠疫情影響下，同店入場人數增長了5%。我們的員工隊伍持續增長並穩定。我們成功地減少了人員流動，護士招聘速度加快並有所改善。

As a result, we reduced contract labor costs during the second quarter of 2023 to about 4.3% of SW&B. With the improving labor environment, we find ourselves in a favorable position to capitalize on our strategic approach to prioritize high acuity specialty services. We feel comfortable with this level of contract labor and will look to prioritize placement of new hires for targeted capacity expansion aligned with our strategy.

因此，我們在 2023 年第二季度將合同勞動力成本降低至 SW&B 的 4.3% 左右。隨著勞動力環境的改善，我們發現自己處於有利地位，可以利用我們的戰略方法來優先考慮高敏銳度專業服務。我們對這種水平的合同工感到滿意，並將優先考慮安置新員工，以實現符合我們戰略的有針對性的產能擴張。

It is important to note that our SW&B as a percent of net revenue was 47.3% for the first half of 2019 and is now running 45% year-to-date in 2023. We see this as a validation of our analytics-driven labor management capabilities, continued portfolio transformation and the higher acuity top line strategy as we recover from the pandemic. It gives us more room to invest, and at the right time, market-by-market, add capacity as we feel comfortable bringing it online.

值得注意的是，2019 年上半年我們的 SW&B 占淨收入的百分比為 47.3%，到 2023 年年初至今該比例為 45%。我們認為這是對我們分析驅動的勞動力管理的驗證隨著我們從疫情中恢復過來，我們的能力、持續的投資組合轉型以及更高敏銳度的營收戰略。它為我們提供了更多的投資空間，並在適當的時間，逐個市場地增加容量，因為我們願意將其上線。

Our business processes utilize real-time analytics to equip staff managers and senior leadership to make data-driven decisions to optimize their areas. This includes workforce productivity, contract labor utilization, inpatient throughput, procedural room utilization, transfer acceptance and more. The analytics are easily digestible and highly accessible with dashboards and insights integrated into key workflows and care team huddles. We believe that this data-driven operating discipline, coupled with our focus on high acuity service line development, will enable our Hospital segment to continue to deliver strong results.

我們的業務流程利用實時分析來幫助員工經理和高級領導層做出數據驅動的決策來優化他們的領域。這包括勞動力生產率、合同勞動力利用率、住院病人吞吐量、手術室利用率、轉運接受率等。通過將儀表板和見解集成到關鍵工作流程和護理團隊中，分析結果易於理解且易於訪問。我們相信，這種數據驅動的運營紀律，加上我們對高敏銳度服務線開發的關注，將使我們的醫院部門繼續取得強勁的業績。

Conifer continues to perform well for its clients and also delivered strong margins; ongoing technology automation and offshoring initiatives support that performance. Second quarter EBITDA margins were 26.3%. Conifer continues to focus on commercial activities, especially in patient eligibility services, given the need from the Medicaid redeterminations.

Conifer 繼續為客戶提供良好的業績，並實現了豐厚的利潤；持續的技術自動化和離岸外包舉措支持了這一業績。第二季度 EBITDA 利潤率為 26.3%。鑑於醫療補助重新確定的需要，康尼弗繼續專注於商業活動，特別是患者資格服務。

Stepping back, I indicated last quarter that our confidence in the ability to turn the various dials on the business and generate predictable results is growing. I like the operating environment right now because it is evolving such that higher acuity focus, effective capacity management and nimble cost control, all strengths of ours, support improving results in our business.

退一步說，我在上個季度表示，我們對調整業務並產生可預測結果的能力的信心正在增強。我喜歡現在的運營環境，因為它正在不斷發展，更高的敏銳度、有效的產能管理和靈活的成本控制，我們的所有優勢，都支持改善我們的業務成果。

As a result, we are again raising our full year 2023 adjusted EBITDA guidance by $75 million at the midpoint to a range of $3.31 billion to $3.46 billion. This range represents a $125 million increase over our initial full year guide. In short, we are optimistic about our ability to continue to differentiate our unique business mix and deleverage through strong earnings growth. Free cash flow continues to improve, which provides us flexibility to make necessary investments to enhance our future growth prospects and improve our capital structure.

因此，我們再次將 2023 年全年調整後 EBITDA 指導上調 7500 萬美元，達到 33.1 億美元至 34.6 億美元的範圍。這一範圍比我們最初的全年指南增加了 1.25 億美元。簡而言之，我們對通過強勁的盈利增長繼續實現獨特業務組合和去槓桿化的能力持樂觀態度。自由現金流持續改善，這為我們提供了進行必要投資的靈活性，以增強我們未來的增長前景並改善我們的資本結構。

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

丹現在將對我們的財務業績進行更詳細的審查。擔？

Thanks, Saum, and hello, everyone. Our financial results in the second quarter were strong, with USPI and the Hospital's adjusted EBITDA, same-store volumes and revenues above our expectations. In the quarter, we generated consolidated adjusted EBITDA of $843 million, above the high end of our second quarter guidance range. Our results were driven by strong same-store revenues and volumes, high patient acuity and effective cost control.

謝謝，索姆，大家好。我們第二季度的財務業績強勁，USPI 和醫院調整後的 EBITDA、同店銷量和收入均超出我們的預期。本季度，我們的綜合調整後 EBITDA 為 8.43 億美元，高於第二季度指導範圍的上限。我們的業績得益於強勁的同店收入和銷量、高度的患者敏銳度和有效的成本控制。

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 continues to provide high-quality care to our patients. In the quarter, USPI produced a 9.8% increase in same-facility net operating revenues compared to last year, with case volumes up 6.6% and net revenue per case up 2.9%. We saw strong growth in GI, urology, ENT and orthopedic cases. USPI's adjusted EBITDA, excluding grant income, grew 16.4% compared to the second quarter of last year, and its margin continues to be very strong at 39.2%. We're pleased with continued strength of USPI's performance, which is a testament to the attractiveness of the portfolio and the value 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。本季度，USPI 的同類設施淨營業收入與去年同期相比增長了 9.8%，箱量增長了 6.6%，每箱淨收入增長了 2.9%。我們看到胃腸道、泌尿科、耳鼻喉科和骨科病例的強勁增長。 USPI 的調整後 EBITDA（不包括贈款收入）與去年第二季度相比增長了 16.4%，其利潤率繼續保持在 39.2% 的強勁水平。我們對 USPI 業績的持續強勁感到高興，這證明了該投資組合的吸引力以及我們為利益相關者提供的價值。

Turning to our acute care hospital business. Second quarter same-hospital adjusted admissions increased 3.2% compared to the second quarter last year and total same-hospital inpatient admissions increased 3%, while non-COVID admissions increased 5%. In fact, year-to-date, non-COVID admissions are up 9.2% over last year.

轉向我們的急症護理醫院業務。與去年第二季度相比，第二季度同一醫院調整後的入院人數增加了 3.2%，同一醫院住院患者總數增加了 3%，而非新冠肺炎入院人數增加了 5%。事實上，今年迄今為止，非新冠肺炎入院人數比去年增加了 9.2%。

Our labor management continues to be very effective despite the cost pressures, especially contract nurse staffing costs. On a consolidated basis, contract labor costs were 4.3% of SW&B in the second quarter, a significant decline from 6% in the first quarter this year, 7.3% in the fourth quarter of last year and 6.2% in the second quarter last year. Our consolidated SW&B costs as a percent of revenue were 45% in the quarter compared to 45.8% in the second quarter last year. And our case mix and revenue yield remained strong as we continue our strategic focus on investments higher acuity, higher margin service lines. And our case mix index in the quarter has grown at a 3% CAGR since 2019 before the pandemic.

儘管存在成本壓力，特別是合同護士人員成本，但我們的勞動力管理仍然非常有效。綜合來看，第二季度合同勞動力成本佔SW&B的4.3%，較今年第一季度的6%、去年第四季度的7.3%和去年第二季度的6.2%大幅下降。本季度我們的綜合 SW&B 成本佔收入的百分比為 45%，而去年第二季度為 45.8%。隨著我們繼續將戰略重點放在投資更高敏銳度、更高利潤的服務線上，我們的案例組合和收入收益率仍然強勁。自 2019 年疫情爆發前以來，我們本季度的病例組合指數複合年增長率為 3%。

Let's now turn to Conifer, which again delivered a solid quarter. Conifer produced second quarter adjusted EBITDA of $85 million and a strong margin of approximately 26%. Overall, we were very pleased with our performance in the second quarter.

現在讓我們看看 Conifer，該公司再次實現了穩健的季度業績。 Conifer 第二季度調整後 EBITDA 為 8500 萬美元，利潤率高達約 26%。總的來說，我們對第二季度的表現非常滿意。

Let's now review our cash flows, balance sheet and capital structure. At the end of the quarter, we had $934 million of cash on hand and no borrowings outstanding under our line of credit. We generated $466 million of free cash flow in the quarter and $680 million so far this year, bolstered by Conifer's strong cash collection performance. As previously announced, in the second quarter, we issued $1.35 billion of secured notes that mature in 2031. We used the proceeds from the notes to early retire $1.345 billion of our then outstanding secured notes that were due next year. We now have no significant debt maturities until 2026. And we have approximately $1.6 billion of secured debt borrowing capacity available if needed.

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。截至本季度末，我們手頭有 9.34 億美元現金，信用額度下沒有未償還借款。得益於 Conifer 強勁的現金回款表現，我們本季度創造了 4.66 億美元的自由現金流，今年迄今創造了 6.8 億美元的自由現金流。正如之前宣布的，我們在第二季度發行了 13.5 億美元的擔保票據，將於 2031 年到期。我們利用票據收益提前償還了明年到期的 13.45 億美元當時未償還的擔保票據。目前，我們在 2026 年之前都沒有重大債務到期。如果需要，我們還有大約 16 億美元的擔保債務借款能力。

Our June 30 leverage ratio was 4.14x EBITDA compared to 4.1x at year-end 2022. Also during the quarter, we repurchased approximately 580,000 shares of our stock for $40 million as part of our $1 billion share repurchase program. Since the inception of the program last year, we have repurchased approximately 7.4 million shares or about 7% of our then outstanding shares for $340 million at an average price of about $46 per share. We believe our strong free cash flow generation and capital deployment actions will continue to provide us ample financial flexibility to support our growth initiatives.

截至6 月30 日，我們的EBITDA 槓桿率為4.14 倍，而2022 年年底為4.1 倍。此外，在本季度，我們以4,000 萬美元的價格回購了約580,000 股股票，作為我們10 億美元股票回購計劃的一部分。自去年該計劃啟動以來，我們以 3.4 億美元的價格回購了約 740 萬股股票，約佔當時已發行股票的 7%，平均價格約為每股 46 美元。我們相信，我們強大的自由現金流生成和資本部署行動將繼續為我們提供充足的財務靈活性，以支持我們的增長計劃。

Let me now turn to our outlook for this year. As Saum mentioned, we are raising our 2023 adjusted EBITDA outlook by $75 million to $3.385 billion at the midpoint of our range, reflecting our continued strong performance. This $75 million increase includes a $45 million raise for USPI and a $30 million raise for our hospitals. Additionally, we now expect net operating revenues to be in the range of $20.1 billion to $20.5 billion, an increase of $300 million.

現在讓我談談我們今年的展望。正如 Saum 提到的，我們將 2023 年調整後 EBITDA 預期上調了 7500 萬美元，達到 33.85 億美元（處於區間中點），反映出我們持續強勁的業績。這 7500 萬美元的增加包括 USPI 的 4500 萬美元的增加和我們醫院的 3000 萬美元的增加。此外，我們現在預計淨營業收入將在 201 億美元至 205 億美元之間，增加 3 億美元。

We've increased our assumptions for growth in hospital inpatient admissions and adjusted admissions. Additionally, at USPI, we have increased our assumption for same facility surgical case growth to 5% to 6% for 2023, a 200 basis point increase over our prior expectations. Our increased full year EBITDA guidance absorbed an approximately $15 million headwind from recently passed legislation in Florida, which, among other things, reduce workers' compensation and personal injury reimbursements.

我們提高了對醫院住院人數增長的假設並調整了入院人數。此外，在 USPI，我們將 2023 年同一設施手術病例增長的假設提高至 5% 至 6%，比我們之前的預期增加了 200 個基點。我們增加的全年 EBITDA 指導吸收了佛羅里達州最近通過的立法帶來的約 1,500 萬美元的阻力，該立法除其他外，還減少了工人賠償和人身傷害報銷。

Regarding our third quarter outlook, we expect consolidated adjusted EBITDA to be in the range of $775 million to $825 million or $800 million at the midpoint. And we anticipate the USPI's EBITDA in the third quarter at the midpoint will be approximately 23% to 24% of our full year 2023 USPI EBITDA guidance of $1.51 billion at the midpoint of our range.

關於我們第三季度的展望，我們預計綜合調整後 EBITDA 將在 7.75 億美元至 8.25 億美元之間，中間值為 8 億美元。我們預計第三季度 USPI 的 EBITDA 中值將約為我們 2023 年全年 USPI EBITDA 指導值 15.1 億美元（我們範圍中值）的 23% 至 24%。

Turning to our cash flows for 2023. From a cash flow perspective, we expect net cash from operating activities to increase $50 million over our prior expectations and are reinvesting this amount back into our business in the form of higher capital expenditures to fuel future growth. As a result, we continue to expect free cash flow to be in the range of $1.1 billion to $1.35 billion for this year. Our free cash flow generation has improved substantially over the past several years, and we expect our business to continue to drive strong cash flows while executing on our growth plans. Our improved cash flow provide us with significant financial flexibility to effectively deploy capital for the benefit of shareholders.

談到2023 年的現金流。從現金流的角度來看，我們預計經營活動產生的淨現金將比我們之前的預期增加5000 萬美元，並將以更高的資本支出的形式將這筆資金重新投資到我們的業務中，以推動未來的增長。因此，我們繼續預計今年的自由現金流將在 11 億美元至 13.5 億美元之間。在過去幾年中，我們的自由現金流產生能力有了顯著改善，我們預計我們的業務在執行增長計劃的同時將繼續推動強勁的現金流。我們改善的現金流為我們提供了顯著的財務靈活性，可以有效地部署資本，為股東謀取利益。

As a reminder, our capital deployment priorities have not changed: first, we plan to continue 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 share repurchases, depending on market conditions and other investment opportunities.

提醒一下，我們的資本部署重點沒有改變：首先，我們計劃繼續每年分配約2.5億美元的資本來發展我們的USPI手術中心業務；其次，增加我們醫院的增長機會，包括繼續關注更高敏銳度的服務產品；第三，根據市場狀況和其他投資機會，進一步評估退休和/或債務再融資和股票回購的機會。

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

這樣，我們就可以開始問答了。操作員？

(Operator Instructions) Our first question today is coming from Steven Valiquette from Barclays.

（操作員說明）我們今天的第一個問題來自巴克萊銀行的 Steven Valiquette。

It's Will McMahon on for Steve. Congrats on the roughly 7% at USPI. Just kind of a quick question on the $45 million full year guidance raise there. In the past, you kind of told us what portion to expect. So what do you think for that for 3Q, and then kind of on the back of it, pretty sizable increase for the full year against the normalized growth rate for EBITDA? Can you just give us a little more color on what's driving the outlook? And maybe anything on payer mix, specifically in the outpatient setting to call out?

威爾·麥克馬洪 (Will McMahon) 替補史蒂夫 (Steve)。恭喜 USPI 獲得大約 7% 的成績。只是簡單詢問一下全年 4500 萬美元的指導募資額。過去，您告訴我們要期待什麼部分。那麼，您對第三季度以及全年 EBITDA 正常化增長率相當大的增長有何看法？您能給我們更多關於推動前景的因素嗎？也許還有關於付款人組合的任何事情，特別是在門診環境中需要注意的事情？

This is Dan. In terms of USPI's guidance for the rest of the year, as I mentioned in my remarks, you may not have heard them, we're anticipating that USPI's Q3 EBITDA would be roughly 23% to 24% of the full year EBITDA guide of $1.51 billion. So that's how we're looking at Q3, and obviously, looking at -- pushes into Q4. Q4 is typically seasonally stronger, and we're still anticipating that. The business has performed incredibly well so far this year with very strong volume growth. The expense management has also been very tight, combating a lot of the inflationary pressures that are out there. And so we're pleased with the results so far. And that's resulted in us increasing their guide by $45 million.

這是丹.就 USPI 對今年剩餘時間的指導而言，正如我在發言中提到的，您可能沒有聽說過，我們預計 USPI 第三季度 EBITDA 將約為全年 EBITDA 指導值 1.51 美元的 23% 至 24%十億。這就是我們看待第三季度的方式，顯然，我們也正在關注第四季度。第四季度通常會季節性更強，我們仍然預計這一點。今年到目前為止，該業務的表現非常好，銷量增長非常強勁。費用管理也非常嚴格，以應對當前的通脹壓力。因此，我們對迄今為止的結果感到滿意。這導致我們將他們的指南增加了 4500 萬美元。

The only other thing I would add to that because you specifically asked about the mix, we feel very good about both the case mix and the payer mix in the recovery and growth this year.

我要補充的唯一一件事是，因為您特別詢問了組合，我們對今年復蘇和增長的案例組合和付款人組合都感覺非常好。

Your next question is coming from Jamie Perse from Goldman Sachs.

你們的下一個問題來自高盛的 Jamie Perse。

I was hoping we could spend a few minutes on just the surgical volumes in the quarter for the Hospital segment. They're obviously very strong for USPI, but I've been a little bit surprised with the trends in the Hospital segment. I think you guys were down about 10 basis points, and outpatient actually looked a little bit weaker than inpatient there. So can you just maybe give us a little bit of color on what you're seeing there? And more importantly, how we should think about the outlook for surgical growth, just given some of the comments you made around backlog recovery. I know those were probably a little more tied to USPI, but still, I would think there'd be some tailwinds there. So any color on that topic would be really helpful.

我希望我們能花幾分鐘時間討論醫院部門本季度的手術量。顯然，USPI 的表現非常強勁，但我對醫院領域的趨勢感到有點驚訝。我認為你們下降了大約 10 個基點，門診實際上看起來比住院要弱一些。那麼您能否給我們一些關於您在那裡看到的情況的信息？更重要的是，考慮到您對積壓恢復的一些評論，我們應該如何考慮手術增長的前景。我知道這些可能與 USPI 的聯繫更緊密一些，但我仍然認為那裡會有一些順風車。因此，關於該主題的任何顏色都會非常有幫助。

Yes. My comments on the backlog and recovery were really meant to address a more fundamental examination we did of the GI service line recovery and growth at USPI. And we're actually happy to be able to report that while some of it appears to be deferred care, a substantial amount of it appears to be new demand stimulation that we're seeing, both in terms of physicians that are ramping up and the ability to expand the service line into the new population supported by the guidelines that's younger and obviously, with most of them, if not all of them being commercially insured. So I think that's a positive tailwind there.

是的。我對積壓和恢復的評論實際上是為了解決我們對 USPI 的 GI 服務線恢復和增長所做的更基本的檢查。我們實際上很高興能夠報告，雖然其中一些似乎是延期護理，但其中很大一部分似乎是我們看到的新需求刺激，無論是在醫生數量增加還是在醫療需求增加方面。能夠將服務範圍擴大到新人群，並得到更年輕的指導方針的支持，顯然，他們中的大多數人（如果不是全部）都有商業保險。所以我認為這是一個積極的推動力。

Look, on the hospital side, I think you guys are aware that we have taken an approach where we've been very thoughtful about our capacity. I think that this is nothing more than a little bit of a mix towards medical versus surgical admissions given the capacity we were willing to open. Obviously, we were still very focused, as you can tell from our results, on the labor side. We were still very focused on bringing down our utilization of expensive contract labor at this point, even with rates moderating, still expensive. And getting that into a target range that we feel comfortable with on an ongoing basis before we begin any type of capacity expansion. So -- yes, we do face some trade-offs at times between what we see coming in medically, especially through the emergency department and a bit of capacity from a surgical standpoint in the acute care hospitals.

聽著，在醫院方面，我想你們都知道我們已經採取了一種對我們的能力進行了非常深思熟慮的方法。我認為，考慮到我們願意開放的容量，這只不過是醫療入院與手術入院的一點混合。顯然，正如您從我們的結果中可以看出的那樣，我們仍然非常關注勞動力方面。此時我們仍然非常注重降低對昂貴合同工的利用率，即使費率有所放緩，但仍然很昂貴。在我們開始任何類型的產能擴張之前，將其持續納入我們感到滿意的目標範圍內。所以，是的，我們有時確實面臨一些權衡，在我們所看到的醫療方面，特別是通過急診室，與急症護理醫院的外科手術能力之間。

Again, we're still managing to a capacity-constrained environment. And that's probably a little bit of what you saw. Look, we feel pretty good about our surgical and our procedural mix investments in the acute care hospitals. There will be some ups and downs as the quarters go from a recovery standpoint. But if you really follow us and you follow our acuity in net revenue intensity, that's really what we're focused on because we think that's going to help generate the best margins over time.

同樣，我們仍然在應對容量有限的環境。這可能就是您所看到的一小部分。看，我們對急症護理醫院的外科手術和程序組合投資感覺非常好。從復甦的角度來看，每個季度都會出現一些起伏。但是，如果您真正關注我們，並且關注我們對淨收入強度的敏銳度，那麼這確實是我們關注的重點，因為我們認為隨著時間的推移，這將有助於產生最佳利潤。

And Jamie, when you look at overall our inpatient revenues on the hospital side on the same-hospital basis, they were up roughly 8%. Outpatient revenues were up year-over-year by 6% and was ahead of our expectations. So we are very pleased with how the hospitals performed overall during the quarter.

傑米（Jamie），當你看看我們在同一家醫院的住院病人收入方面，你會發現它們增長了大約 8%。門診收入同比增長 6%，超出我們的預期。因此，我們對醫院在本季度的整體表現感到非常滿意。

Next question is coming from Pito Chickering from Deutsche Bank.

下一個問題來自德意志銀行的 Pito Chickering。

For guidance, looking at both hospitals and USPI, it looks like that they're modeling case growth and adjusted admissions to normalize in the back half of the year? I just -- I guess, the math here, possible, you did about a 5% same-store adjusted admission in the first half of the year. It implies about 2% for the back half. And for USPI, you did about 7.2% case growth. It implies about [4%] in the back half of the year. Are you seeing anything to be conservative about the normalized case growth? Or is there any conservatism? And if these current volumes remain, will there be upside to your guidance? And any color on July?

作為指導，看看醫院和 USPI，看起來他們正在對病例增長進行建模，並調整入院人數以在今年下半年恢復正常？我只是——我想，這裡的數學，可能的，你在今年上半年做了大約 5% 的同店調整入場費。這意味著後半部分大約為 2%。對於 USPI，您的病例增長了約 7.2%。這意味著下半年大約[4%]。您認為正常化病例增長有什麼保守的地方嗎？或者說有什麼保守主義嗎？如果當前的銷量保持不變，您的指導會有上升空間嗎？七月有什麼顏色嗎？

Yes. Well, no color on July, but the -- I mean, I think you've hit on some important points. I mean, first of all, even as you described, normalized, I mean, the full year guidance on USPI volumes is still ahead now of what we think the long-term trends would look like. And obviously, if the volumes are stronger, the chassis has proven just like in this quarter and the first quarter, it can certainly outperform expectations from an earnings standpoint.

是的。好吧，七月沒有顏色，但是——我的意思是，我認為你已經抓住了一些重要的觀點。我的意思是，首先，即使正如您所描述的那樣，正常化後，USPI 交易量的全年指導現在仍然領先於我們認為的長期趨勢。顯然，如果銷量更加強勁，底盤已經被證明就像本季度和第一季度一樣，從盈利的角度來看，它肯定可以超出預期。

And so look, I think the biggest thing to think about here is Q4 seasonality tends to be pretty robust at USPI, and we see no reason to believe that that's going to be any different this year. But 6%, 7%, 7.2%, as you point out, I mean, that's pretty significant growth. And I think it's prudent to look ahead in a much better than normal year, but also ensure that we're thoughtful about what we're seeing from a volume perspective that we can really truly predict looking forward.

因此，我認為這裡要考慮的最重要的事情是 USPI 的第四季度季節性往往相當強勁，我們認為沒有理由相信今年的情況會有所不同。但正如你所指出的，6%、7%、7.2%，這是相當顯著的增長。我認為，明智的做法是展望比正常情況更好的一年，但也要確保我們從數量角度考慮我們所看到的情況，以便我們能夠真正預測未來。

Same thing on the hospital side. Q4 tends to be stronger there. It's not as seasonal in its variation as USPI, but it is somewhat seasonal, somewhat driven by different things, including respiratory illness and other things. And I think, again, I think the guidance reflects there, both our optimism about the business and also some planning around adding capacity back in if we can maintain the contract labor environment and labor cost environment the way that we finally got it to where we're comfortable.

醫院那邊也是同樣的情況。第四季度往往會更強。它的變化不像 USPI 那樣季節性，但它在某種程度上是季節性的，在某種程度上是由不同的因素驅動的，包括呼吸道疾病和其他因素。我認為，我認為該指引既反映了我們對業務的樂觀態度，也反映了我們對增加產能的一些計劃，如果我們能夠維持合同勞工環境和勞動力成本環境，就像我們最終達到的那樣。很舒服。

Yes. And the only other thing I'd add, Pito, is listen in the back half of the year, we're assuming at the midpoint, admissions grow about 2.4% roughly. And in the third quarter last year, COVID admissions were roughly 6% of cases and roughly 4% in the fourth quarter. We're not expecting the same level of COVID volumes, obviously, in the back half of this year at this point. But again, we -- the volumes performance has been very good on the hospital side. And overall, the hospitals have outperformed our expectations.

是的。 Pito，我唯一要補充的另一件事是，在今年下半年，我們假設在中點，招生人數大約增長 2.4%。去年第三季度，新冠入院病例約佔病例的 6%，第四季度約為 4%。顯然，我們預計今年下半年的新冠疫情數量不會達到同樣水平。但同樣，我們——醫院方面的銷量表現非常好。總體而言，醫院的表現超出了我們的預期。

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

下一個問題來自沃爾夫研究中心的賈斯汀·萊克。

I appreciate it. Just a couple of numbers questions. First, physician outsourcing has been a hot topic and certainly it looks like your other operating costs were up a bit. Just curious what's going on there or maybe you can give us a ballpark estimate of what that physician outsourcing costs or physician costs are within that other operating as a percentage? And then just lastly, on your payer mix on the hospital side. Given you include Managed, Medicaid and Medicare in there, I'd love to hear just a pure commercial number and how that looked year-over-year.

我很感激。只是幾個數字問題。首先，醫生外包一直是一個熱門話題，當然，您的其他運營成本似乎有所上升。只是好奇那裡發生了什麼，或者您可以給我們一個大概的估計，即醫生外包成本或醫生成本在其他業務中所佔的百分比？最後，關於醫院方面的付款人組合。鑑於其中包括託管、醫療補助和醫療保險，我很想听到一個純粹的商業數字以及與去年同期相比的情況。

I'll take the first one and Dan will take the second one. So Justin, just a few thoughts on the physician outsourcing and hospital-based physician staffing costs have been an area of focus for us. We've talked about them since the pandemic began and have been a focus for us over that period of time. Not surprisingly, there's pressure in the industry based upon some of the reimbursement and market discontinuities that those entities have faced. But this isn't something new, right?

我將選擇第一個，丹將選擇第二個。賈斯汀，關於醫生外包和醫院醫生人員成本的一些想法一直是我們關注的焦點。自大流行開始以來，我們就一直在討論它們，並且一直是我們在那段時間的關注焦點。毫不奇怪，由於這些實體面臨的一些報銷和市場不連續性，該行業面臨壓力。但這不是什麼新鮮事，對吧？

So our -- I mean, if you look forward, our guidance in both of our care delivery segments -- takes into account -- and our robust increase in guidance takes into account what we think will happen with respect to costs in that line item. So yes, there's cost pressure there. We also work on mitigating that by improving utilization of the physician resources that we have by consolidating and combining service lines where possible. And certainly, with our work with some of our preferred partners in that area, they're growing their market share with us because they provide better opportunities for us to partner. And selectively, because of our contracting strategies, including outpatient, we're selectively to in-source where needed seamlessly in order to manage our expense base there. So I do think this is an important area, but it's not -- at least my reflection is it's not new, and we've been managing it for some time.

因此，我們的——我的意思是，如果你展望未來，我們在兩個護理服務領域的指導——考慮到——並且我們指導的強勁增長考慮到了我們認為該行項目的成本將會發生的情況。所以，是的，那裡存在成本壓力。我們還努力通過盡可能整合和合併服務線來提高我們擁有的醫生資源的利用率，從而減輕這種情況。當然，通過我們與該領域一些首選合作夥伴的合作，他們正在與我們一起擴大市場份額，因為他們為我們提供了更好的合作機會。並且有選擇地，由於我們的合同策略（包括門診），我們有選擇地無縫地在需要的地方進行內包，以管理我們在那裡的費用基礎。所以我確實認為這是一個重要的領域，但事實並非如此——至少我的想法是它並不新鮮，而且我們已經管理它有一段時間了。

And Justin, on the -- from a payer mix perspective, the payer mix in the quarter is really consistent with the first quarter. It continues to remain attractive from a commercial perspective with in and outpatient volumes tracking stronger than the aggregate inpatient/outpatient volumes. And the revenue yield has been very good as well. So again, we're satisfied with the payer mix trends.

賈斯汀，從付款人組合的角度來看，本季度的付款人組合確實與第一季度一致。從商業角度來看，它仍然具有吸引力，入院和門診量均強於住院/門診總量。而且收入收益率也非常好。再說一次，我們對付款人組合趨勢感到滿意。

Your next question today is coming from Kevin Fischbeck from Bank of America.

今天你們的下一個問題來自美國銀行的 Kevin Fischbeck。

I wanted to go into your point about temp labor now being at a point where you can kind of invest in growth. Is there some way to quantify kind of where admissions or volumes might be if you had full staff just to kind of frame how much volume is deferred volume? And then when we think about -- it sounds like there's a staffing aspect to it, which might be shorter term and there's a CapEx aspect to it which maybe longer term. So I'd love to just kind of think about -- how to think about that volume recovery and whether it's right to think that one could be above average if you're able to staff and grow out the CapEx you're talking about?

我想談談你關於臨時工的觀點，現在你可以投資於增長。如果您有完整的員工，是否有某種方法可以量化入場量或交易量可能的情況，只是為了確定延遲交易量的數量？然後，當我們考慮時，聽起來好像有一個人員配置方面，這可能是短期的，還有一個資本支出方面，可能是長期的。因此，我想思考一下——如何考慮銷量恢復，以及如果您能夠配備人員並增加您所談論的資本支出，那麼認為銷量可能高於平均水平是否正確？

Yes. Kevin, I think a couple of thoughts. I mean, I think the CapEx and infrastructure constraints are really minimal. There may be certain service lines where our current physician capacity or particular areas of the hospital in services we've invested in are a bit full. But in general, I would not say that we have physical capacity constraints to be able to grow. It's more about the service lines that we want to be in.

是的。凱文，我有幾個想法。我的意思是，我認為資本支出和基礎設施的限制確實很小。在某些服務領域，我們目前的醫生能力或我們投資的醫院特定領域的服務可能有點滿。但總的來說，我不會說我們的成長受到身體能力的限制。更多的是關於我們想要進入的服務領域。

From a labor standpoint, I mean 4.3% is a blended number across our portfolio, obviously. And it's a little bit different market to market in terms of what we're doing. What we really -- and therefore, the ability to take market share, if that's where the growth is, is really something we're selective about based upon both the service lines and the payer mix that we service in those markets. So in some of our markets, we're already investing and adding capacity and feel pretty good about the results. In other markets, we're a bit more cautious based upon the underlying mix or case mix that we tend to see in that area. But in all cases, as time goes on, if contract labor costs and premium labor costs continue on the path of normalizing, we think we'll have additional room for volume growth as we look forward.

從勞動力的角度來看，我的意思是 4.3% 顯然是我們投資組合的混合數字。就我們正在做的事情而言，不同的市場略有不同。我們真正的——以及因此獲得市場份額的能力，如果這就是增長所在，實際上是我們根據我們在這些市場中提供服務的服務線和付款人組合進行選擇的。因此，在我們的一些市場中，我們已經進行了投資並增加了產能，並對結果感到非常滿意。在其他市場，我們根據我們在該領域傾向於看到的潛在組合或案例組合更加謹慎。但在所有情況下，隨著時間的推移，如果合同勞動力成本和溢價勞動力成本繼續走上正常化的道路，我們認為我們未來將有額外的銷量增長空間。

Finally, you asked the question about how much is really deferred. My general view has been on the acute care side, not much of it is really deferred care. I mean it's different than maybe what others are seeing. I'm not really sure. But at least for us, I have not really seen or viewed patterns that suggest to me a large fraction of what we're seeing right now in the acute care side is deferred and somehow going to be one and done.

最後，您問了實際推遲了多少的問題。我的總體觀點是在急性護理方面，其中真正的延期護理並不多。我的意思是這可能與其他人看到的不同。我不太確定。但至少對我們來說，我還沒有真正看到或觀察過一些模式，這些模式對我來說表明我們現在在急症護理方面看到的很大一部分都被推遲了，並且以某種方式完成了。

Our next question is coming from Calvin Sternick from JPMorgan.

我們的下一個問題來自摩根大通的卡爾文·斯特尼克。

I had a question on the geographic mix. Were there any that [setout] that were sort of particularly strong in the quarter and you're seeing a rebound in maybe some of the markets that were slower to recover initially? And then just on USPI, can you give an update on the M&A pipeline and some of the physician buy-ups from SCD too. Just wondering if any -- if there's any sort of impact on how physicians are thinking about potential buyouts just given the strong volume environment.

我有一個關於地理組合的問題。是否有任何[設置]在本季度特別強勁，並且您可能看到一些最初復甦較慢的市場出現反彈？然後，在 USPI 上，您能否介紹一下併購渠道的最新情況以及 SCD 的一些醫生收購情況。只是想知道在強勁的銷量環境下是否會對醫生考慮潛在收購的方式產生任何影響。

Yes. Just taking them in reverse. I'll take the first one, Dan, if you want to take the first -- the second one if you want to take the first one. Look, nothing to report out of the ordinary on the SCD buy-ups like we mentioned last time, those are on track with our expectations this year. And while we're at it, just the de novos that we're going to open that were delayed are all on track this year as well. And obviously, that's been a contributor to an overall very, very strong first half of the year for USPI.

是的。只是把它們反過來看。丹，如果你想選第一個，我就選第一個；如果你想選第一個，我就選第二個。看，就像我們上次提到的那樣，關於 SCD 收購沒有什麼異常的報告，這些都符合我們今年的預期。在我們這樣做的同時，我們要重新開業但被推遲的項目今年也都步入正軌。顯然，這對 USPI 今年上半年整體表現非常非常強勁做出了貢獻。

Yes. Calvin, in terms of the geographic markets or areas from a hospital perspective. What I would say -- I'm not going to get into like specifics about each geography. But what I would say is the volume growth that we're reporting is not primarily due to certain geographies that have reopened at a slower pace than others. So it's not like the Florida and Texas markets are not big contributors to this performance. And it's being driven by some of the other markets, whether California or Michigan. The markets are performing well, and these volume trends are not because there's 1 or 2 markets that just reopened slower and that's what's driving all this growth. That is not the case.

是的。 Calvin，從醫院的角度來看地理市場或區域。我想說的是——我不會詳細討論每個地區的具體情況。但我想說的是，我們報告的銷量增長並不是主要由於某些地區重新開放的速度比其他地區慢。因此，佛羅里達州和德克薩斯州市場對這一表現的貢獻並不大。它是由其他一些市場推動的，無論是加利福尼亞州還是密歇根州。市場表現良好，這些成交量趨勢並不是因為有一兩個市場重新開放速度較慢，而這才是推動所有增長的原因。事實並非如此。

Your next question is coming from Whit Mayo from Leerink Partners.

您的下一個問題來自 Leerink Partners 的 Whit Mayo。

Just back on the physician staffing point or the question. Are you seeing any changes in anesthesia coverage at USPI? Meaning are we seeing groups ask for increase subsidies? Are you seeing any disruption on volumes in any markets from the dislocation with these groups? I know you said it's manageable so, but I'm going to just -- I guess I'm trying to kind of unpack maybe what's sort of new relative to USPI.

回到醫生人員配備點或問題上來。您發現 USPI 的麻醉覆蓋範圍有任何變化嗎？這意味著我們是否看到團體要求增加補貼？您是否發現任何市場的交易量因這些群體的混亂而受到干擾？我知道你說這是可以管理的，但我想——我想我正在嘗試解開相對於 USPI 的新內容。

Yes. This is a little bit like the contract labor discussions that we have. It's just -- it's sort of not -- the issues on the hospital side are so much more significant than anything we see on the USPI side because the mix is good, and it's just a different environment to operate in. And so the magnitude of that effect that USPI is so much lower than the challenges that are being faced on the hospital side with respect to anesthesia staffing.

是的。這有點像我們進行的合同工討論。只是 - 有點不是 - 醫院方面的問題比我們在 USPI 方面看到的任何問題都要重要得多，因為組合很好，而且只是一個不同的運營環境。這種影響使得USPI 遠遠低於醫院方面在麻醉人員配置方面面臨的挑戰。

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

我們的下一個問題來自 A.J.瑞士信貸的大米。

Just maybe talk about 2 other areas you haven't mentioned. Some are saying they're seeing some of the benefit from all the growth we've seen on the public exchanges or marketplaces, whatever you want to call them. I heard you talk about what your strategy has been with respect to marketplace for a while. What -- are you -- do you feel like you're in the most contracts there? And how much is that? I assume that's being booked in the managed care line, but I just want to confirm that and how much of a tailwind does that provide year-to-year for you?

也許只是談談你沒有提到的其他兩個領域。有些人說，他們看到了我們在公共交易所或市場（無論你想怎麼稱呼它們）上看到的所有增長所帶來的一些好處。我聽到你談論一段時間以來你的市場策略是什麼。你覺得你籤的合同是那裡最多的嗎？那是多少錢？我認為這是在管理式醫療系列中預訂的，但我只是想確認這一點，以及這每年為您提供多少順風車？

And then, on the same lines, obviously, there's the question of Medicaid redeterminations. You've got a couple of markets that tend to be a little heavier Medicaid. Are you -- what are you seeing in early days there? Are you actively involved in getting people reverified? And is there upside because some of those people may end up on the exchanges for you there?

然後，同樣，顯然還有醫療補助重新確定的問題。有幾個市場的醫療補助往往比較重。你在早期看到了什麼？您是否積極參與讓人們重新獲得驗證？這是否有好處，因為其中一些人可能最終會在那里為你進行交易所？

Yes, A.J., thanks for the question. I think it's early days on redetermination, first of all. So we're not really seeing much effect. And it's -- I'm glad you raised that because I'll reinforce, Conifer has a best-in-class eligibility and enrollment service. And it benefits us, it benefits our clients. And now as I've indicated, we're expanding that as a point solution. So we feel very, very good about our ability to catch and capture eligible patients, whether they're moving from one form of insurance to another, Medicaid to exchange or other, or even from the standpoint of those that may enter the system apparently uninsured but actually do qualify for coverage. And by the way, that includes even in this environment, a lot of new enrollments in Medicaid that we achieved.

是的，A.J.，謝謝你的提問。首先，我認為重新確定還處於早期階段。所以我們並沒有真正看到太大的效果。我很高興你提出這個問題，因為我要強調的是，康尼弗擁有一流的資格和註冊服務。這對我們有利，對我們的客戶也有利。現在，正如我所指出的，我們正在將其擴展為單點解決方案。因此，我們對我們吸引和吸引符合條件的患者的能力感到非常非常滿意，無論他們是從一種保險形式轉向另一種形式，從醫療補助轉向交換或其他形式，甚至從那些可能進入系統但顯然沒有保險的人的角度來看但實際上確實有資格獲得承保。順便說一句，即使在這種環境下，我們也實現了醫療補助計劃的大量新註冊。

Our exchange strategy has been very consistent for many years. We took the approach early on of contracting broadly in the exchanges and doing that on a commercial minus rather than a Medicare plus basis. So we're pleased with the rates and we're pleased with the network access. As narrow networks have opened up, including some ultra narrow networks, there may be some or a handful that we're not in, but they really don't have a lot of lives in them. And so for the networks that are gaining a lot of lives or have a lot of lives, we tend to be very well contracted. It has been a long-standing strategy of the company to be broadly inclusive of exchange patients.

多年來我們的交流策略一直非常一致。我們很早就採取了在交易所廣泛簽訂合同的方法，並在商業減項而不是醫療保險加項的基礎上進行。因此，我們對費率和網絡訪問感到滿意。隨著窄網絡的開放，包括一些超窄網絡，可能有一些或少數我們不在其中，但它們裡面確實沒有很多生命。因此，對於正在獲得大量生命或擁有大量生命的網絡，我們往往會進行很好的契約。廣泛包容交換患者一直是公司的長期戰略。

And A.J., the exchange volumes that we care for and the revenues, they are included in that managed care line you see that we disclose. And I would tell you the exchange volumes and revenues are trending very nicely, like overall, it's part of our commercial when we think about our commercial mix. Trends are good.

A.J.，我們關心的交易量和收入，它們包含在您看到的我們披露的管理式醫療產品線中。我想告訴你，交易量和收入的趨勢非常好，總的來說，當我們考慮我們的商業組合時，它是我們商業的一部分。趨勢是好的。

Next question is coming from Andrew Mok from UBS.

下一個問題來自瑞銀集團 (UBS) 的安德魯·莫 (Andrew Mok)。

You've done about $90 million of share repurchase to date and have $660 million of authorization remaining through 2024. You've increased the CapEx guide by about $50 million. But curious to hear what your thoughts around share repurchase have changed and with a better cash flow profile this year.

迄今為止，您已完成約 9000 萬美元的股票回購，到 2024 年還有 6.6 億美元的授權剩餘。您已將資本支出指南增加了約 5000 萬美元。但很想知道您對股票回購的想法發生了哪些變化，並且今年的現金流狀況有所改善。

This is Dan. No, there's absolutely no change in our views and how we're thinking about share repurchases. We obviously repurchased some additional shares in the quarter. And we'll continue to look at that in terms of -- from a capital allocation perspective, as we always say. Depending on other investment opportunities and market conditions, we will certainly continue to pursue share repurchases. So no change whatsoever from our thinking on share repurchases. We increased our CapEx guidance with additional investments to drive additional growth substantially on the hospital side.

這是丹.不，我們的觀點以及我們對股票回購的看法絕對沒有改變。我們顯然在本季度回購了一些額外的股票。正如我們常說的那樣，我們將繼續從資本配置的角度來看待這一問題。根據其他投資機會和市場狀況，我們肯定會繼續進行股票回購。因此，我們對股票回購的想法沒有任何改變。我們通過額外投資提高了資本支出指導，以大幅推動醫院方面的額外增長。

Yes. I would echo that, especially on the first point. I mean, as our business strengthens, and in particular, the long-term trends that would support, especially the Ambulatory Surgery division growing over time as we come out of the pandemic. We still feel that our equity is a very, very compelling investment vehicle as we trade even on an EBITDA minus NCI basis, we still trade at a discount to some of our peers, whether you look at it by segment or in total. So we very much feel like that our business prospects have a lot of upside associated with them.

是的。我同意這一點，尤其是在第一點上。我的意思是，隨著我們業務的加強，特別是長期趨勢的支持，特別是隨著我們走出大流行，門診手術部門隨著時間的推移而增長。我們仍然認為我們的股票是一種非常非常有吸引力的投資工具，因為即使我們以 EBITDA 減去 NCI 為基礎進行交易，我們仍然比一些同行有折扣，無論是按細分市場還是總體來看。因此，我們非常覺得我們的業務前景有很多與之相關的好處。

Thank you. Your next question today is coming from Brian Tanquilut from Jefferies.

謝謝。今天你們的下一個問題來自 Jefferies 的 Brian Tanquilut。

Congratulations. Saum, as I think about the revenue per adjusted admission in the hospital up 4%, pretty strong, how should we be thinking about your ability to sustain that healthy level, both from an acuity perspective and maybe some of the contract negotiations with the payers as we look at obviously higher than average inflation rates?

恭喜。 Saum，我認為調整後的入院收入增長了 4%，相當強勁，我們應該如何考慮您維持健康水平的能力，無論是從敏銳度角度還是從與付款人的一些合同談判角度來看正如我們所看到的，通貨膨脹率明顯高於平均水平？

Yes. Look, maybe Dan and I will both comment. Look, I think the acuity strategy, we still have runway across our markets. And I actually think, as we come out of the pandemic, if we continue to focus on expanding our initiatives in that area, we ought to be able to sustain. On a non-COVID basis, our case mix index has been growing at a 3% CAGR since 2019, which in the CMI world is a very, very strong result.

是的。聽著，也許丹和我都會發表評論。看，我認為敏銳的戰略，我們在市場上仍然有跑道。事實上，我認為，當我們走出大流行後，如果我們繼續專注於擴大我們在該領域的舉措，我們應該能夠維持下去。在非新冠疫情的基礎上，我們的病例組合指數自 2019 年以來一直以 3% 的複合年增長率增長，這在 CMI 領域是一個非常非常強勁的結果。

I mean this has been a strategy prepandemic, as you know, that we undertook when some of us joined the company to really reposition Tenet's acute care hospital portfolio, and we've been working at that for a long time, and we continue to work at it and think that there will be upside there. And then from a contracting perspective, as we -- part of strengthening the attractiveness of our portfolio, has been upgrading the reputation and quality of physicians that choose to work in our hospitals, which create a lot of pull among consumers, employers and other things, and that has definitely been the case.

我的意思是，正如你所知，這是大流行前的一項戰略，當我們中的一些人加入公司時，我們就採取了這一戰略，以真正重新定位特尼特的急症護理醫院投資組合，我們已經為此工作了很長時間，並且我們將繼續努力並認為那裡會有好處。然後從簽約的角度來看，作為增強我們投資組合吸引力的一部分，我們一直在提升選擇在我們醫院工作的醫生的聲譽和質量，這在消費者、雇主和其他方面產生了很大的吸引力，情況確實如此。

It's been the case pre and post now pandemic in terms of what we're doing. And that helps our contracting because our hospitals are more desirable from a quality reputation and program standpoint than they were 5 years ago. And as a consequence, if I look at our recent contracting efforts, they're better than what they were 2 or 3 years ago in terms of the kinds of escalators we're able to negotiate because we're more must-have in some ways in the networks in the cities in which we operate. So this can be a virtuous cycle I believe that will continue for some time.

就我們正在做的事情而言，大流行前後都是這種情況。這有助於我們簽訂合同，因為從質量聲譽和項目的角度來看，我們的醫院比 5 年前更受歡迎。因此，如果我看看我們最近的承包工作，就我們能夠談判的自動扶梯種類而言，它們比兩三年前要好，因為我們在某些方面更必須擁有我們運營所在城市的網絡中的方式。所以這可能是一個良性循環，我相信會持續一段時間。

Your next question is coming from Jason Cassorla from Citi.

您的下一個問題來自花旗銀行的 Jason Cassorla。

Great. Just wanted to ask about your cash flow and CapEx guide. It sounds like you're up both in context of better EBITDA generation this year. Just obviously, cash flow, you've done $466 million year-to-date. You updated free cash flow guide of $1.35 billion. There's an operationally strong fourth quarter to consider. I'm just wondering if there's any timing elements that we should consider as it relates to cash flow and CapEx spend? And then just as a quick follow-up, if there's any onetime items we should be thinking about in the back half of the year on EBITDA, like Medicaid supplemental payments or otherwise?

偉大的。只是想問一下您的現金流和資本支出指南。聽起來你們今年的 EBITDA 生成情況似乎都不錯。顯然，現金流方面，今年迄今為止您已完成 4.66 億美元。您更新了 13.5 億美元的自由現金流指南。需要考慮的是運營強勁的第四季度。我只是想知道我們是否應該考慮任何與現金流和資本支出相關的時間因素？然後，作為一個快速跟進，是否有任何一次性項目我們應該在今年下半年考慮 EBITDA，例如醫療補助補充付款或其他？

This is Dan, Jason. In terms of free cash flow generation, obviously, we're pleased with how our performance has been so far this year. Conifer has done a really good job. It is outperforming our expectations. So that's very encouraging.

這是丹，傑森。顯然，就自由現金流產生而言，我們對今年迄今為止的業績感到滿意。康尼弗做得非常好。它的表現超出了我們的預期。所以這非常令人鼓舞。

Your point about the timing, I would say there's -- we still have some tax payments to make in the fourth quarter that wouldn't necessarily maybe seen in the third quarter. But really no substantive change from our thinking other than the strong performance so far. And we -- as we mentioned, we made a decision, we're going to invest a little bit more into CapEx this year, $50 million.

我想說的是，你關於時間安排的觀點是——我們仍然需要在第四季度繳納一些稅款，而這些稅款不一定會在第三季度看到。但除了迄今為止的強勁表現之外，我們的想法確實沒有發生實質性變化。正如我們所提到的，我們做出了一個決定，今年我們將在資本支出上多投資一點，即 5000 萬美元。

Your next question is coming from Stephen Baxter from Wells Fargo.

你們的下一個問題來自富國銀行的斯蒂芬·巴克斯特。

This [Nick] on for Steve. I was hoping you could provide an update on the performance of the SCD businesses so far this year and where you are in terms of progression to the effective multiples you target for those assets.

這位[尼克]代表史蒂夫。我希望您能提供有關今年迄今為止 SCD 業務業績的最新信息，以及您在實現這些資產目標有效倍數方面的進展情況。

Yes, I did that earlier. We're very pleased with the ongoing buy-ups according to plan this year and the opening of the de novos. And U.S., it's been a contributor to the entirety of USPI's performance this year, which has been strong on both acuity and growth. And as Dan mentioned also, a lot of the work we've done on operations management that has improved margins and strengthened margins as well.

是的，我之前就這麼做過。我們對今年按計劃進行的持續收購以及重新開業感到非常滿意。而美國，它為今年 USPI 的整體業績做出了貢獻，其敏銳度和增長都非常強勁。正如丹也提到的，我們在運營管理方面所做的很多工作都提高了利潤率並增強了利潤率。

Next question is coming from Ben Hendrix from RBC Capital Markets.

下一個問題來自加拿大皇家銀行資本市場的本·亨德里克斯。

I appreciate all the color on the growth across USPI case categories, but I don't know if I heard you mention cardio growth. Just want some comments on your degree of focus there and what you're seeing in that area?

我很欣賞 USPI 案例類別中生長的所有顏色，但我不知道我是否聽到你提到有氧生長。只是想談談您對該領域的關注程度以及您在該領域所看到的情況嗎？

Yes. No, of course, we're very attuned to the cardiovascular market in the ASC setting. We perform peripheral and device-based work there today, and very selectively other types of vascular -- coronary vascular work. Look, this is an area in which I have consistently voiced caution about how rapidly it will expand. One, because of patient safety and selection issues that still have to be worked out. So we're in the midst of a number of different pilots to work out appropriate safe clinical protocols. I mean, ASCs are small businesses and a single patient error and associated liability can really do a lot of damage there. So we're very careful and cautious about developing the right set of protocols in that environment if we're going to expand into cardiovascular in a more broad way.

是的。不，當然，我們非常適應 ASC 環境中的心血管市場。今天，我們在那裡進行外圍設備和基於設備的工作，並且非常有選擇性地進行其他類型的血管——冠狀血管工作。看，我一直對這個領域的擴張速度表示謹慎。第一，因為患者安全和選擇問題仍有待解決。因此，我們正在進行許多不同的試點，以製定適當的安全臨床方案。我的意思是，ASC 是小型企業，患者的一個錯誤和相關責任確實可能會造成很大的損失。因此，如果我們要更廣泛地擴展到心血管領域，我們會非常謹慎地在這種環境下制定一套正確的方案。

The second thing you just have to realize is that, the payer mix, because it's cardiac, tends to be much, much more heavily Medicare than commercial. Even if you compare to orthopedics, which has a lot of commercial activity. And that is going to impact the types of margins that those types of facilities can generate. Now look, I recognize USPI has got best-in-class margins for the ASC business by far. But part of what you got to work out is how to do this, build the scale and do it with margins that are healthy so that the partnership with physicians stays engaged in building that. So my view here is that, will things move into the outpatient setting in that field? Sure. But I think it's going to be slower and more cautious all around because of the things I mentioned than what some people discuss.

您必須意識到的第二件事是，付款人組合，因為它是心臟性的，往往是醫療保險比商業要多得多。即使與有很多商業活動的骨科相比。這將影響這些類型的設施可以產生的利潤類型。現在看，我認識到 USPI 的 ASC 業務利潤率迄今為止是一流的。但你需要解決的部分問題是如何做到這一點，建立規模並以健康的利潤來做到這一點，以便與醫生的合作夥伴關係繼續致力於建立這一目標。所以我的觀點是，該領域的情況會進入門診嗎？當然。但我認為，由於我提到的事情比一些人討論的事情，一切都會更慢、更謹慎。

Thank you. We reached the end of our question-and-answer session. And 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。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，度過美好的一天。我們感謝您今天的參與。