Tenet Healthcare Corp (THC) 2023 Q3 法說會逐字稿

Good afternoon. Welcome to Tenet Healthcare's Third Quarter 2023 Earnings Conference Call. (Operator Instructions) I'll now turn the call over to your host, Mr. Will McDowell, Vice President of Investor Relations. Mr. McDowell, you may begin.

午安.歡迎參加 Tenet Healthcare 2023 年第三季財報電話會議。 （接線員指示）我現在將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 third 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, Chairman and Chief Executive Officer; Dan Cancelmi, Executive Vice President and Chief Financial Officer; and Sun Park, Executive Vice President.

大家下午好，感謝您參加今天的電話會議。我是投資人關係副總裁威爾‧麥克道爾。我們很高興您與我們一起討論 Tenet 2023 年第三季的業績以及我們的財務前景。參加今天電話會議的 Tenet 高階管理層包括董事長兼執行長 Saum Sutaria 博士； Dan Cancelmi，執行副總裁兼財務長；和執行副總裁 Sun Park。

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.

今天下午我們的網路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資訊做出的預期。實際結果和計劃可能存在重大差異。 Tenet 沒有義務根據後續資訊更新任何前瞻性聲明。投資人應注意今天簡報中包含的警示性聲明投影片，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. We continue to deliver strong results in 2023. In the third quarter, we generated net operating revenues of $5.1 billion and consolidated adjusted EBITDA of $854 million. This translates into an attractive, almost 17% margin. These results were driven by sustained volume growth and effective cost control across each of our businesses.

謝謝威爾，大家下午好。 2023 年，我們將繼續取得強勁業績。第三季度，我們實現淨營運收入 51 億美元，綜合調整後 EBITDA 為 8.54 億美元。這意味著近 17% 的利潤率極具吸引力。這些業績是由我們每項業務的持續銷售成長和有效的成本控制所推動的。

USPI had another very strong quarter with $370 million of adjusted EBITDA, which represents 16% growth compared with third quarter 2022. Same-facility revenues grew 7.9% and adjusted EBITDA margins remained robust. USPI had attractive volume growth in high-acuity service lines, including mid-teens growth in total joint replacements in the ASCs over third quarter 2022. We also delivered ongoing strength in GI, urology, and ENT procedures. We remain focused on attracting high-quality physicians who choose to practice in our low-cost, high patient satisfaction setting of care. This, coupled with tailwinds from increased patient demand for ambulatory surgery care will support continued organic growth.

USPI 又一個非常強勁的季度，調整後 EBITDA 達到 3.7 億美元，與 2022 年第三季度相比增長 16%。同一設施收入增長 7.9%，調整後 EBITDA 利潤率依然強勁。 USPI 在高敏銳度服務領域的銷售成長引人注目，包括2022 年第三季ASC 關節置換總數的中位數成長。我們在胃腸道、泌尿科和耳鼻喉科手術方面也保持了持續的優勢。我們仍然致力於吸引選擇在我們低成本、高患者滿意度的護理環境中執業的高素質醫生。再加上患者對門診手術護理需求增加的推動力，將支持持續的有機成長。

We also remain committed to scaling our portfolio. During the quarter, we added 6 new centers, the majority of which were focused on higher acuity orthopedic services. These included centers in Nevada, Maryland, Texas, and Florida, all with leading regional musculoskeletal specialists. Our acquisition pipeline remains robust with attractive opportunities. We also have a healthy de novo development pipeline of more than 30 centers currently in the syndication stages all the way to being under construction. Notably, de novo centers have effective EBITDA multiples in the low single digits, making them a very attractive use of capital that further advances the site of service value-based care which USPI uniquely delivers.

我們也繼續致力於擴大我們的投資組合。本季度，我們新增了 6 個中心，其中大部分專注於更高敏銳度的骨科服務。其中包括內華達州、馬裡蘭州、德克薩斯州和佛羅裡達州的中心，所有中心都擁有領先的地區肌肉骨骼專家。我們的收購管道仍然強勁，並提供有吸引力的機會。我們也擁有健康的從頭開發管道，其中包括 30 多個中心，目前正處於聯合階段，一直到在建階段。值得注意的是，新生中心的有效 EBITDA 倍數處於低個位數，這使其成為一種非常有吸引力的資本用途，進一步推進了 USPI 獨特提供的基於服務價值的護理領域。

Turning to our Hospital segment, we generated $401 million of adjusted EBITDA in the third quarter 2023. Our patient acuity levels remained strong with revenue per adjusted admission up 3.2% over third quarter 2022. Additionally, on a non-COVID basis, same-store inpatient admissions increased 4.5%. Our hospitals continue to enhance access to higher acuity services for the benefit of our patients. For example, our Arizona Heart Hospital was the first in Arizona to implant a new device to reduce stroke risk, and our Palm Beach Gardens Medical Center expanded its robotic surgical capabilities. We will continue to increase patient access to cutting-edge specialty care across the communities we serve. Our third quarter results lend further credence to our hospital strategy of being focused on acuity rather than all things to all people.

談到我們的醫院部門，我們在2023 年第三季產生了4.01 億美元的調整後EBITDA。我們的病患敏銳度水準仍然強勁，每次調整後的入院收入比2022 年第三季成長了3.2% 。此外，在非新冠疫情的基礎上，同店住院人數增加了 4.5%。為了病人的利益，我們的醫院持續提高獲得更高敏銳度服務的機會。例如，我們的亞利桑那州心臟醫院是亞利桑那州第一家植入新設備以降低中風風險的醫院，我們的棕櫚灘花園醫療中心擴大了其機器人手術能力。我們將繼續在我們服務的社區中增加患者獲得尖端專業護理的機會。我們第三季的業績進一步證明了我們醫院的策略，即專注於敏銳度，而不是為所有人提供一切服務。

We continue to make significant progress improving nurse retention and accelerating hiring. This has resulted in a substantial reduction in contract labor usage to 3.1% of consolidated SW&B, which is the high end of pre-pandemic levels. Given our progress in hiring and retention, the reductions in contract labor did not come at the expense of further capacity reductions. We reached these levels in advance of our own projections through disciplined data-driven processes. We will balance the utilization of contract labor for nurses with our targeted strategies to increase capacity to support patient demand for high acuity services. In the fourth quarter, as demand rises, it is possible we will invest additional resources to ensure access, continuing to employ the same discipline we have used in contract labor utilization over the past 2 years.

我們繼續在提高護理師留任率和加速招聘方面取得重大進展。這導致合約工使用量大幅減少至綜合 SW&B 的 3.1%，這是疫情前水準的高端。鑑於我們在招募和留任方面取得的進展，合約工的減少並不以進一步削減產能為代價。透過嚴格的數據驅動流程，我們比自己的預測提前達到了這些水準。我們將平衡護理師合約工的使用與我們的有針對性的策略，以提高支持患者對高敏銳度服務需求的能力。在第四季度，隨著需求的增加，我們可能會投入更多資源來確保准入，繼續採用過去兩年在合約工利用方面所採用的相同紀律。

We continue to manage cost pressures from medical fees. Medical fees, while higher than last year, remained relatively flat from Q2 to Q3 '23. As I noted through the pandemic, we began a process of restructuring our staffing contracts market by market, which includes decisions on in-sourcing services where that is most beneficial. This has helped to mitigate the magnitude of expense increases in our business. Again, as patient demand rises into the winter, we anticipate some increases in costs from our current run rate to ensure access to our specialty services, but this will not change our longer-term discipline nor our make versus buy strategy.

我們持續應對醫療費用帶來的成本壓力。醫療費用雖然高於去年，但從 2023 年第二季到第三季仍相對持平。正如我在疫情期間指出的那樣，我們開始了逐個市場重組我們的人員合約的過程，其中包括對最有利的內包服務做出決定。這有助於減輕我們業務費用增加的幅度。同樣，隨著冬季患者需求的增加，我們預計當前的運行成本會增加，以確保獲得我們的專業服務，但這不會改變我們的長期紀律，也不會改變我們的自製與外購策略。

Finally, I want to point out that over the last 2 years we have successfully settled over 30 labor union contract negotiations. These require a delicate balance between understanding our employees' needs and our ability to have a cost structure to deliver affordable care for our patients. We will continue with our strategy to balance those 2 aspects.

最後我想指出，兩年來我們已經成功解決了30多起工會合約談判。這需要在了解員工的需求和我們的成本結構為患者提供負擔得起的護理的能力之間取得微妙的平衡。我們將繼續實施平衡這兩個面向的策略。

Before I turn my attention to Conifer, I'll make a few comments about our views on the GLP-1 receptor agonists potential impact on our business. These products are very early in their life cycle of impact. They have extraordinarily high costs, an expanding list of side effects, patient tolerance issues and concerns about lean muscle loss, which translates into an unknown long-term safety profile. We believe that this means adoption among populations which could benefit is still and likely to be for some time, low. Additionally, these products require sustained consumption. The underlying conditions of diabetes or the related root causes of obesity are not cured.

在我將注意力轉向 Conifer 之前，我將就我們對 GLP-1 受體激動劑對我們業務的潛在影響的看法發表一些評論。這些產品仍處於影響生命週期的早期階段。它們的成本非常高，副作用不斷增加，患者耐受性問題以及對瘦肌肉損失的擔憂，這轉化為未知的長期安全性。我們認為，這意味著可能受益的人群的採用率仍然很低，並且可能在一段時間內處於較低水平。此外，這些產品需要持續消費。糖尿病的潛在病症或肥胖的相關根本原因尚未治癒。

Given this, we see no reason to alter our current focus on taking care of patients with multiple chronic illnesses and we see no reason to alter our capital plans in moving care into convenient ambulatory settings. The high acuity strategy in the hospitals is subject to less demand elasticity, and the capital-efficient business model we've designed to take care of the most complex needs of patients will endure. The aging of the population, the growing burden of chronic illness, the population shifts into many of our markets and the continued impacts of service and technology innovation that occur outside of the pharmaceutical sector provide a significant tailwind for the important role that hospitals and ASCs will continue to play.

有鑑於此，我們認為沒有理由改變目前對多種慢性病患者的照護重點，也沒有理由改變我們將照護轉移到方便的門診環境的資本計畫。醫院的高敏銳度策略受到的需求彈性較小，而我們為滿足患者最複雜的需求而設計的資本效率高的商業模式將持續下去。人口老化、慢性病負擔日益加重、人口轉移到我們的許多市場以及製藥行業之外的服務和技術創新的持續影響，為醫院和 ASC 的重要作用提供了重要的推動力。繼續玩。

Turning to Conifer. Our Conifer business continues to deliver strong margins and provide high-quality services to its clients. This performance has been supported by ongoing automation and offshoring initiatives and third quarter EBITDA margins were over 26%. We recently renewed our long-standing relationship with one of our larger physician revenue cycle management clients and are slated for additional renewals by the end of the year.

轉向針葉樹。我們的針葉樹業務繼續為客戶帶來豐厚的利潤並提供高品質的服務。這一業績得益於持續的自動化和離岸外包計劃，第三季 EBITDA 利潤率超過 26%。我們最近與一家較大的醫生收入周期管理客戶續簽了長期合作關係，並計劃在今年年底前進一步續簽。

Before I turn the call over to Dan, I want to reiterate the strength of our portfolio of businesses and the ongoing performance they have produced. While we continue to navigate a challenging environment, our strategic focus on higher acuity services, agile approach to managing operating expenses and effective capacity management, all play a pivotal role in delivering these durable results. As a result, we are again raising our full year 2023 adjusted EBITDA guidance to a range of $3.365 billion to $3.465 billion. We're still formulating plans for 2024, and we'll take the time to see what a fourth quarter looks like in the post-pandemic environment before getting specific about our guidance for next year.

在將電話轉給 Dan 之前，我想重申我們業務組合的實力以及它們所產生的持續業績。在我們繼續應對充滿挑戰的環境的同時，我們對更高敏銳度服務的策略重點、管理營運費用的敏捷方法和有效的容量管理，都在實現這些持久成果方面發揮著關鍵作用。因此，我們再次將 2023 年全年調整後 EBITDA 指引提高至 33.65 億美元至 34.65 億美元的範圍。我們仍在製定 2024 年的計劃，在具體制定明年的指導之前，我們將花時間了解大流行後環境下第四季度的情況。

From a capital deployment perspective, our priorities are consistent: USPI expansion at very attractive post-synergy multiples and investments in the growth of our high acuity strategy in the acute care segment. Those 2 priorities help to reduce leverage through earnings growth and free cash flow generation. We maintain an opportunistic balance in this public market trading environment between our desire to pay down debt more directly and the very attractive valuation of our equity. I will remind you that we have all fixed rate debt and no maturities due until 2026, providing a great deal of predictability relative to other companies that may have a similar level of leverage.

從資本部署的角度來看，我們的優先事項是一致的：USPI 以非常有吸引力的協同後倍數擴張，並投資於我們在急診護理領域的高敏銳度策略的成長。這兩個優先事項有助於透過獲利成長和自由現金流產生來降低槓桿。在這種公開市場交易環境中，我們在更直接地償還債務的願望與極具吸引力的股權估值之間保持著機會主義平衡。我要提醒您的是，我們的債務都是固定利率的，而且在2026 年之前都沒有到期日，因此相對於其他可能具有類似槓桿水平的公司而言，我們提供了很大的可預測性。

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 third quarter were strong with USPI and our Hospital's adjusted EBITDA well above our expectations. In the quarter, we generated consolidated adjusted EBITDA of $854 million, above the high end of our third quarter guidance range. Our results were driven by strong same-store revenues and volumes, high patient acuity and very effective cost control.

謝謝，索姆，大家好。我們第三季的財務表現強勁，USPI 和我們醫院調整後的 EBITDA 遠高於我們的預期。本季度，我們的綜合調整後 EBITDA 為 8.54 億美元，高於第三季指引範圍的上限。我們的業績得益於強勁的同店收入和銷售、高度的患者敏銳度以及非常有效的成本控制。

Now I'd like to highlight a few key items for each of our segments. Let's start with USPI which delivered strong volume and earnings growth. In the third quarter, USPI produced a 7.9% increase in same-facility system-wide revenues compared to last year, with case volumes up 4.1% and net revenue per case up 3.7%. And USPI's adjusted EBITDA grew 16% compared to the third quarter of last year. Adjusted EBITDA minus NCI expense increased 12%, and its EBITDA margin continues to be very strong at 39.3%. We are pleased with the continued strength of USPI's performance as we grow this business both organically and inorganically in attractive markets across the country.

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，它實現了強勁的銷量和盈利增長。第三季度，USPI 的同設施全系統收入與去年相比增長了 7.9%，箱量增長了 4.1%，每箱淨收入增長了 3.7%。 USPI 的調整後 EBITDA 與去年第三季相比成長了 16%。調整後 EBITDA 減去 NCI 費用後成長了 12%，其 EBITDA 利潤率仍非常強勁，達到 39.3%。我們對 USPI 業績的持續強勁感到高興，因為我們在全國各地有吸引力的市場中有機和無機地發展了這項業務。

Turning to our acute care hospital business. Same-hospital inpatient admissions increased 0.6% compared to the third quarter last year, while non-COVID admissions increased 4.5%. In fact, year-to-date, non-COVID admissions are up 7.6% over last year. Our labor management continues to be very effective, especially temporary contract nurse staffing costs. On a consolidated basis, contract labor costs were just 3.1% of SW&B in the quarter, a significant decline from 4.3% in the second quarter this year and 7.4% in the third quarter of last year, a year-over-year decline of almost 60%.

轉向我們的急診醫院業務。與去年第三季相比，同一家醫院的住院人數增加了 0.6%，而非新冠肺炎住院人數增加了 4.5%。事實上，今年迄今為止，非新冠肺炎入院人數比去年增加了 7.6%。我們的勞動力管理仍然非常有效，特別是臨時合約護理師的人員成本。綜合來看，本季合約勞動成本僅佔 SW&B 的 3.1%，較今年第二季的 4.3% 和去年第三季的 7.4% 大幅下降，年減了近60%。

Our consolidated SW&B costs as a percent of revenue were just 45.2% in the quarter compared to 46.4% in the third quarter last year and 250 basis points lower than the 47.6% reported in Q3 2019 before the pandemic despite the significant inflationary pressures since then. Medical fees were flat sequentially compared to the second quarter of this year and were $34 million higher than the third quarter of 2022, consistent with our expectations. Overall, these costs are up 15% year-to-date.

本季我們的綜合 SW&B 成本佔營收的百分比僅為 45.2%，而去年第三季為 46.4%，比疫情爆發前 2019 年第三季的 47.6% 低 250 個基點，儘管此後通膨壓力巨大。醫療費用與今年第二季相比持平，比 2022 年第三季增加 3,400 萬美元，與我們的預期一致。總體而言，今年迄今這些成本上漲了 15%。

And finally, our case mix and revenue yield remain strong as we continue our strategic focus on investments in higher acuity, higher margin service lines. I want to reiterate what we've communicated previously, our hospital strategy has focused on growing higher acuity volumes, which is working, better margins, stronger ability to manage costs and more capital efficient to generate the earnings growth.

最後，隨著我們繼續將策略重點放在對更高敏銳度、更高利潤率服務線的投資上，我們的案例組合和收入收益率仍然強勁。我想重申我們之前溝通過的內容，我們的醫院策略重點是提高有效的敏銳度、更好的利潤、更強的成本管理能力以及更高的資本效率，以實現獲利成長。

Let's now turn to Conifer, which again delivered a solid quarter. Conifer produced third quarter adjusted EBITDA of $83 million and a strong margin of 26.3% and continued its strong revenue cycle performance for our hospitals and its other clients.

現在讓我們看看 Conifer，該公司再次實現了穩健的季度業績。 Conifer 第三季調整後 EBITDA 為 8,300 萬美元，利潤率為 26.3%，繼續為我們的醫院和其他客戶帶來強勁的收入週期表現。

Now let's review our cash flows, balance sheet and capital structure. At the end of the quarter, we had over $1 billion of cash on hand and no borrowings outstanding under our $1.5 billion line of credit facility. We generated $327 million of free cash flow in the third quarter and just over $1 billion year-to-date, bolstered by Conifer's strong cash collection performance. Our September 30 leverage ratio was 4.08x EBITDA. As a reminder, all of our outstanding senior secured and unsecured notes have fixed interest rates, and we have no significant debt maturities until 2026. We believe our strong free cash flow generation and capital deployment actions will continue to provide us financial flexibility to support our growth initiatives and further deleverage the balance sheet.

現在讓我們回顧一下我們的現金流量、資產負債表和資本結構。截至本季末，我們手頭現金超過 10 億美元，15 億美元信貸額度下沒有未償還借款。由於 Conifer 強勁的現金回款表現，我們第三季創造了 3.27 億美元的自由現金流，今年迄今創造了略高於 10 億美元的自由現金流。截至 9 月 30 日，我們的槓桿率為 4.08 倍 EBITDA。提醒一下，我們所有未償還的優先擔保和無擔保票據都有固定利率，而且我們在2026 年之前沒有重大債務到期。我們相信，我們強大的自由現金流產生和資本部署行動將繼續為我們提供財務靈活性，以支持我們的業務。成長舉措並進一步去槓桿化資產負債表。

Let me now turn to our increased outlook for this year. As Saum mentioned, we are raising our 2023 adjusted EBITDA outlook range by $30 million to $3.415 billion at the midpoint of our range, reflecting our continued strong performance. This $30 million increase includes a $10 million raise for USPI and a $20 million raise for our hospitals. This is the third time we've raised our EBITDA guidance this year, which is now $155 million or 5% higher than our initial guidance we shared at the beginning of the year. Additionally, we now expect net operating revenues to be in the range of $20.3 billion to $20.5 billion, an increase of $100 million at the midpoint over previous expectations.

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 EBITDA 展望範圍上調了 3000 萬美元，達到 34.15 億美元（中點），這反映了我們持續強勁的業績。這 3000 萬美元的增加包括 USPI 的 1000 萬美元的增加和我們醫院的 2000 萬美元的增加。這是我們今年第三次上調 EBITDA 指導，目前該指導值比我們年初分享的初始指導高出 1.55 億美元，即 5%。此外，我們現在預計淨營業收入將在 203 億美元至 205 億美元之間，比先前預期的中位數增加 1 億美元。

Turning to our cash flows for '23. We now expect free cash flow to be in the range of $1.125 billion to $1.350 billion.

轉向我們 23 年的現金流。我們現在預計自由現金流將在 11.25 億美元至 13.50 億美元之間。

Now I'd like to spend a minute discussing 2024. We are still conducting our 2024 business planning processes and evaluating key assumptions, and therefore, it is premature at this point for us to provide specifics on 2024 guidance. However, we do want to give you some context for our current thinking about next year.

現在我想花一點時間討論 2024 年。我們仍在進行 2024 年業務規劃流程並評估關鍵假設，因此，現在提供 2024 年指導的具體細節還為時過早。然而，我們確實想為您提供一些我們目前對明年的想法的背景資訊。

Our starting point assumes that we will continue to produce organic volume growth in our key service lines, increase patient acuity, benefit from better than historical contract negotiations and effectively manage costs with a specific expectation for full year additional contract labor savings. And given the robust pipelines at USPI, we will have further contributions from M&A and de novo development center openings. These factors, in addition to an ongoing post-pandemic recovery for health care services provide tailwinds into next year.

我們的出發點是假設我們將繼續在關鍵服務領域實現有機數量增長，提高患者的敏銳度，從比歷史更好的合約談判中受益，並有效管理成本，並具體期望全年額外節省合約勞動力。鑑於 USPI 的強大管道，我們將從併購和從頭開發中心的開設中獲得進一步的貢獻。這些因素，再加上疫情後醫療保健服務的持續復甦，為明年提供了有利條件。

Our starting point also assumes some rather obvious points in this year's results, such as the absence of further grand income and cybersecurity proceeds. In addition, we anticipate completing our sale of the San Ramon Hospital, subject to regulatory approvals. The termination of COVID-related government funding programs as well as the new regulations related to workers' compensation and personal injury reimbursement in Florida and health care wages in California represent around $100 million in headwinds in aggregate. However, thus far in our planning, we expect our earnings growth opportunities will more than offset these headwinds.

我們的出發點也假設了今年業績中的一些相當明顯的點，例如沒有進一步的巨額收入和網路安全收益。此外，我們預計將在獲得監管部門批准的情況下完成聖拉蒙醫院的出售。與新冠肺炎相關的政府資助計劃的終止以及佛羅裡達州工人賠償和人身傷害報銷以及加州醫療保健工資相關的新規定總共帶來了約 1 億美元的不利影響。然而，到目前為止，在我們的規劃中，我們預計我們的獲利成長機會將足以抵消這些不利因素。

I would reiterate Saum's point that the current environment for recovery in health care services is positive and we feel well positioned to continue our success. We look forward to completing the planning and sharing guidance with you for 2024 in February on our earnings call. We are pleased with our strong performance so far this year and have confidence in our ability to deliver on our increased 2023 adjusted EBITDA guidance of $3.415 billion at the midpoint of the range.

我想重申索姆的觀點，即當前醫療保健服務的復甦環境是積極的，我們感覺有能力繼續取得成功。我們期待在 2 月的財報電話會議上完成 2024 年的規劃並與您分享指導。我們對今年迄今的強勁表現感到滿意，並對我們有能力實現 2023 年調整後 EBITDA 指導值的中位數 34.15 億美元充滿信心。

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 is coming from Josh Raskin from Nephron Research.

（操作員說明）我們的第一個問題來自 Nephron Research 的 Josh Raskin。

Just a quick clarification, Dan. When you say earnings growth will more than make up those headwinds, are you just suggesting EBITDA will be up for 2024 and we can figure out magnitude in February? And then my real question is just has to do with the ASC segment, specifically seeing same-store growth moderate a little bit while pricing is picking up, so cases moderate a little bit while pricing picks up. So -- and same-store revenues are still at very high single-digit range each quarter. Is that simply just more complex cases to the outpatient setting? Is that the focus on higher-acuity specialties or some of the new centers you're opening more multi-specialty? Is there something else in there? And then it sounds like you expect that to persist into 2024. Is that the sort of run rate that you're seeing in sort of high single-digit same-store revenue growth? Is that a fair assumption for next year?

只是快速澄清一下，丹。當您說獲利成長將足以彌補這些不利因素時，您是否只是暗示 2024 年 EBITDA 將上漲，我們可以在 2 月計算出上漲幅度？然後我真正的問題是與 ASC 細分市場有關，特別是在定價上漲的同時看到同店增長略有放緩，因此在定價上漲的同時案例略有放緩。因此，每季的同店收入仍然處於非常高的個位數範圍。這只是門診環境中更複雜的病例嗎？是專注於更高敏銳度的專業還是您正在開設的一些更多專業的新中心？裡面還有別的東西嗎？聽起來您預計這種情況將持續到 2024 年。您所看到的同店收入高單位數增長是這種運行率嗎？對於明年來說，這是一個合理的假設嗎？

Josh, it's Dan. I'll take the first part about 2024 and then Saum will address the USPI points. Yes, we are assuming EBITDA growth in 2024 compared to this year. Obviously, you just heard some of my remarks, outlined some of the various positives as we think about next year, also taking into consideration some of the other items that will go the other way just because the reduction in government COVID funding. We're not anticipating any additional grant income next year or cyber income. We're obviously still pursuing cyber insurance proceeds. We feel we're certainly entitled to additional proceeds, but we're not -- at this point, we're not going to assume anything for the guidance next year.

喬什，是丹。我將討論 2024 年的第一部分，然後 Saum 將討論 USPI 要點。是的，我們假設 2024 年 EBITDA 較今年有所成長。顯然，你們剛剛聽到了我的一些言論，概述了我們明年考慮的一些積極因素，同時也考慮到了一些其他項目，這些項目將因為政府新冠疫情資金的減少而出現相反的情況。我們預計明年不會有任何額外的贈款收入或網路收入。顯然我們仍在追求網路保險收益。我們認為我們當然有權獲得額外收益，但我們沒有——在這一點上，我們不會對明年的指導做出任何假設。

And as we talked about, in the past, there's some reimbursement headwinds in Florida and then as well as the new wage regulations in California. So all those items, all the headwinds, so to speak, are roughly $100 million in aggregate or in total.

正如我們所討論的，過去佛羅裡達州存在一些報銷阻力，然後加州也有新的工資規定。因此，所有這些項目、所有不利因素，可以說，總計約為 1 億美元。

Josh, it's Saum. On the ASC growth, we're obviously quite pleased with continued growth rates well above our long-term projections for the business of 2% to 3% organic growth. And so while there may be moderation from the first part of the year to the third quarter, it's still incredibly robust growth, so I'm very pleased with that continuing strength. And obviously, we continue to build acuity into our ASCs and see that in the net revenue per case at the same time. So we feel pretty good about what the business is achieving right now with so much momentum so far for the full year. And as you know, the Q4 ramp for USPI is real, and it's something that we're really interested in seeing and we're well prepared for as the first kind of post-pandemic Q4 to see how that goes. We haven't really formulated '24 guidance on that so I'll defer the '24 guidance question.

喬什，我是索姆。在 ASC 成長方面，我們顯然對持續成長率感到非常滿意，成長率遠高於我們對業務 2% 至 3% 有機成長的長期預測。因此，雖然從今年上半年到第三季可能會放緩，但成長仍然令人難以置信的強勁，所以我對這種持續的強勁成長感到非常滿意。顯然，我們繼續提高 ASC 的敏銳度，同時在每個案例的淨收入中看到這一點。因此，我們對公司目前所取得的成就感到非常滿意，全年到目前為止勢頭強勁。如您所知，USPI 第四季度的成長是真實的，這是我們真正感興趣的事情，我們已經做好了充分準備，作為大流行後的第一個第四季度，看看情況如何。我們還沒有真正制定 '24 指導方針，所以我將推遲 '24 指導問題。

Next question is coming from Stephen Baxter from Wells Fargo.

下一個問題來自富國銀行的史蒂芬‧巴克斯特。

Wanted to ask about the revised guidance and the implied fourth quarter in there. So for the Hospital segment, it does look like your guidance EBITDA, that's a little bit lower sequentially at the midpoint, especially if we're going to adjust out the incremental insurance proceeds you had in the third quarter. Normally we'd expect EBITDA to grow in the fourth quarter as volume picks up. We also understand that your guidance here is a bit better. And then I think you mentioned again like something kind of a wait-and-see approach around Q4 performance post-COVID. Just wanted to clarify, have you seen something different at this point in Q4? Just trying to understand whether that's more prudence or something you're actually seeing in the results today as we're most through October.

想詢問修訂後的指導和其中隱含的第四季。因此，對於醫院部門來說，它確實看起來像您的指導 EBITDA，在中點處連續有點低，特別是如果我們要調整您在第三季度的增量保險收益的話。通常，隨著銷售量的增加，我們預計第四季度 EBITDA 將成長。我們也知道您在這裡的指導更好一些。然後我想你又提到了對新冠疫情後第四季業績的某種觀望態度。只是想澄清一下，您在第四季度的這一點上看到了什麼不同嗎？只是想了解這是否更謹慎，或者您在今天的結果中實際看到的東西，因為我們已經過了十月了。

So let me start and I'll pass to Dan. Just going in reverse order, we're not seeing anything different at this stage, although we are cognizant of the fact that there are lots of reports out there about COVID spreading and the penetration of the vaccine that is supposedly effective against this strain being at somewhere around 7%, I think, in the U.S. population. So this is a little bit of post-traumatic stress, right, in the sense that we've been through surprise COVID spikes before. We're hopeful that, that doesn't happen again. We're certainly not seeing evidence of it in our hospitals at this point in time. But I've said from the beginning of the year and even late last year that we're really looking forward to seeing and digging into a Q4 without COVID to understand how the business and the demand environment performs from that perspective.

那麼就讓我開始吧，我將交給丹。只是以相反的順序，我們在現階段沒有看到任何不同，儘管我們認識到有很多關於新冠病毒傳播和疫苗滲透的報道，而這種疫苗據稱可以有效對抗這種病毒株。我認為，在美國人口中大約有7% 左右。所以這是一點創傷後壓力，對吧，從某種意義上說，我們之前經歷過新冠疫情的意外激增。我們希望這種情況不會再發生。目前我們的醫院當然還沒有看到這方面的證據。但我從今年年初甚至去年底就說過，我們真的很期待看到並深入研究沒有新冠疫情的第四季度，從這個角度了解業務和需求環境的表現。

Stephen, it's Dan. In terms of the sequential walk from Q3 to Q4, so in -- obviously, looking at our USPI business, we are expecting sequential growth there consistent with what we have seen in the past. So we're -- we've -- obviously, the performance has been strong this year, and everything we're seeing so far would suggest we'll see sequential growth in the USPI business.

史蒂芬，我是丹。就從第三季到第四季的連續成長而言，顯然，看看我們的 USPI 業務，我們預計那裡的連續成長與我們過去所看到的一致。所以我們——我們——顯然，今年的業績一直很強勁，到目前為止我們所看到的一切都表明我們將看到 USPI 業務的連續成長。

Listen, on the hospitals, there were some items there in the third quarter, whether it's grant income or cyber proceeds, we're assuming they won't be there in Q4. There will be some additional reimbursement reductions related to COVID funding, in particular, FMAP phasing down further. And then as Saum pointed out in his remarks, we're -- when we think about contract labor, maybe we might invest some more in the fourth quarter, if necessary, to meet the volume demand. And we also built into our assumptions of some additional medical fees in the fourth quarter.

聽著，在醫院方面，第三季有一些項目，無論是贈款收入還是網路收益，我們假設它們不會在第四季度出現。與新冠病毒相關的資金將進一步減少一些報銷，特別是 FMAP 進一步逐步減少。然後，正如索姆在演講中指出的那樣，當我們考慮合約工時，如果有必要，也許我們可能會在第四季度進行更多投資，以滿足產量需求。我們也假設了第四季會產生一些額外的醫療費用。

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

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

Yes, I was just curious on Slide 10 of the PowerPoint presentation. The 103 new service lines added year-to-date for USPI, just to confirm, does that include de novos from this year? And just any common themes around that? Just is this all joints? Any cardio? Just what are the service lines and maybe how that 103 number compares to the new services last year?

是的，我只是對 PowerPoint 簡報的幻燈片 10 感到好奇。今年迄今為止，USPI 增加了 103 條新服務線，只是為了確認一下，這是否包括今年的新增服務線？還有與之相關的共同主題嗎？這都是關節嗎？有氧運動嗎？到底有哪些服務線？也許 103 的數量與去年的新服務相比如何？

Yes, Whit, this does not include de novos, service line additions or expansions of services in existing ambulatory surgery centers. And obviously, consistent with our priorities, what we're looking to do is add higher acuity services, in many cases, orthopedics into existing centers that may be single specialty but have additional capacity, or if they're multi-specialty centers, that don't have orthopedics work going on in them, looking to add orthopedics in those settings.

是的，惠特，這不包括從頭開始、增加服務線或擴大現有門診手術中心的服務。顯然，與我們的優先事項一致，我們要做的是在現有中心中增加更高的敏銳度服務，在許多情況下，將骨科服務添加到現有的中心，這些中心可能是單一專業但具有額外的能力，或者如果它們是多專業中心，那麼其中沒有進行骨科工作，希望在這些環境中添加骨科工作。

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。

As far as my question, I just want to say I'm not sure if this is Dan's last earnings call, but if it is, it's been a pleasure to work with you and congrats on the retirement. My question is around the surgery center business. So a couple of things. One, there's been some discussion out there that MedPAC is talking about volumes kind of moderating a bit September into October. Just curious if you're hearing that out there or seeing anything in your business that would imply a bit of a slowdown.

就我的問題而言，我只想說，我不確定這是否是丹的最後一次財報電話會議，但如果是的話，很高興與您合作，並祝賀您退休。我的問題是關於手術中心業務的。有幾件事。第一，有一些討論稱 MedPAC 正在談論 9 月至 10 月的銷量有所放緩。只是好奇您是否聽過這種說法或在您的業務中看到任何可能意味著放緩的情況。

And then can you flesh out a little bit, the last time we were together, the -- you did mention the excitement. It feels like there's been a pickup in the M&A pipeline, the de novo pipeline. Maybe give us a little bit of color in terms of how that's shaping up going into next year versus how it's looked the last 2 or 3 years.

然後你能具體說一下，上次我們在一起的時候，你確實提到了興奮。感覺併購管道（從頭管道）有所回升。也許可以給我們一些關於明年的情況與過去兩三年的情況的一些資訊。

Yes. Thanks, Justin. I don't -- I haven't seen the MedPAC report and I'm not going to comment on October or early fourth quarter volumes other than to say, reiterate what I said before, which is -- this is shaping up to be a terrific year for volume growth at USPI. The M&A environment is consistently positive. We don't see that we're -- we don't see that there's higher multiples required as centers recover on their own that might have been up for sale over the last couple of years. We have a lot of opportunities in diligence from that perspective. And at the same time, given where interest rates are, we've actually gone through a process internally of raising our bar on the assessment process that we use, in particular, around the financial returns and the ability to drive the post-synergy multiples down to where we've said they would go.

是的。謝謝，賈斯汀。我沒有——我沒有看到 MedPAC 報告，我不會對 10 月或第四季初的銷售發表評論，只是重申我之前說過的話——這將是USPI 銷量增長驚人的一年。併購環境始終積極。我們沒有看到，隨著過去幾年可能出售的中心自行恢復，我們沒有看到需要更高的倍數。從這個角度來看，我們在勤勉方面有很多機會。同時，考慮到利率水平，我們實際上已經在內部經歷了一個提高我們使用的評估流程標準的過程，特別是圍繞財務回報和推動協同後倍數的能力直到我們說過他們會去的地方。

On the de novo opportunities, those have a lead time, obviously, once you start moving of around 18 months or more. But having this many in the pipeline is great because 2 things happen from that perspective. One is that you're usually building new higher acuity orthopedics-focused centers in markets where physicians haven't really been in the ASC setting before so it's a net increase of activity; and two, by moving things into a lower-cost setting, it continues to enhance the value-based care proposition of USPI. And we're kind of focused on both of those. So I feel pretty good about both areas at this point heading into 2024. Dan?

對於從頭開始的機會，顯然，一旦您開始移動，這些機會就有大約 18 個月或更長時間的準備時間。但有這麼多正在醞釀中是很棒的，因為從這個角度來看，會發生兩件事。一是，您通常會在醫生之前從未真正接觸過 ASC 環境的市場中建立新的、以更高敏銳度為重點的骨科中心，因此這是活動的淨增長；第二，透過將事情轉移到更低成本的環境中，它繼續增強 USPI 基於價值的護理主張。我們有點關注這兩點。因此，進入 2024 年，我對這兩個領域都感覺非常好。丹？

Justin, it's Dan. This will be my last earnings call but thanks for remembering that. I really appreciate that. It's been really an honor representing the company. And I just want to say thanks to all of the company's employees, the physicians, all the caregivers and our volunteers at our hospitals and facilities. They really do amazing things every day. If you spend any time at the hospital, you see that very quickly. So I just want to thank all of them.

賈斯汀，我是丹。這將是我最後一次財報電話會議，但感謝您還記得這一點。我真的很感激。能夠代表公司真的是一種榮幸。我只想對公司的所有員工、醫生、所有護理人員以及我們醫院和設施中的志工表示感謝。他們真的每天都在做令人驚奇的事。如果您在醫院待過一段時間，您很快就會看到這一點。所以我只想感謝他們所有人。

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

今天的下一個問題來自美國銀行的 Kevin Fischbeck。

And I guess I'll add my thanks to Dan as well. But I guess as far as my question goes, when you were talking about the potential tailwinds into next year, one of the things you spiked out was the post-pandemic recovery from COVID, providing a good operating backdrop into next year. I guess where do you think we are today in that recovery? And I guess I'm interpreting that as a volume comment, but if there's something else you would also be specking out not quite back to normal on the cost side or whatever it is. Would love to kind of get a sense of where we are in that recovery in your view today.

我想我還要感謝丹。但我想就我的問題而言，當您談論明年的潛在有利因素時，您提到的其中一件事是新冠疫情後的復甦，為明年提供了良好的營運背景。我想您認為我們今天在復甦中處於什麼位置？我想我將其解釋為數量評論，但如果還有其他問題，您也會指出成本方面或其他方面並未完全恢復正常。我很想了解您今天認為我們在復甦中所處的位置。

It's both. I mean, it's both. It's -- I mean, the volume recovery, especially in the acute care business and related services on an elective basis will continue to grow. And I think that part of this is, obviously, we had a lot of premature mortality from COVID way back in the beginning, 2020-ish, early 2020 to '21. And I think as the population continues to age in, despite that premature mortality, we'll see a tailwind of demand.

兩者都是。我的意思是，兩者都是。我的意思是，銷售恢復，特別是在急診業務和選擇性相關服務方面將繼續成長。我認為這顯然是部分原因，早在 2020 年初、2020 年初到 21 世紀，我們就有很多人因新冠肺炎而過早死亡。我認為，儘管存在過早死亡，但隨著人口繼續老化，我們將看到需求的強勁增長。

Now look, the cost side, whether it be in labor, which is the most obvious or supply chain side still has room to go to normalize. I mean, our performance this year in the Hospital business has been a combination of volume in the high acuity area that we focused on but also beating our expectations on how much expensive contract labor we would be able to reduce from the business. And as I said, in this quarter, it came without any cost to capacity because of our hiring efforts. But I still think there's room -- there's still room to move from a normalization standpoint over the next couple of years. And certainly, that's the basis of the comment for 2024.

現在看，成本方面，無論是最明顯的勞動力方面，還是供應鏈方面，還有正常化的空間。我的意思是，我們今年在醫院業務中的表現不僅是我們重點關注的高敏銳度領域的銷量，而且超出了我們對我們能夠從該業務中減少多少昂貴合約勞動力的預期。正如我所說，在本季度，由於我們的招募工作，它沒有造成任何產能成本。但我仍然認為還有空間——從正常化的角度來看，未來幾年仍有進步的空間。當然，這是 2024 年評論的基礎。

Next question is coming from A.J. Rice from UBS.

下一個問題來自 A.J.瑞銀的米。

Best wishes, Dan, as well. Have been struggling a lot about managed care on the call, where are you at with your contracting for '24 and '25? I know you've got a lot of national contracts. What kind of the increases are you seeing? Are you still getting some incremental bump for the labor challenges that the industry has faced or is it starting to sort of normalize as you look out for the next year or 2 in rates? Any thoughts there?

也祝愿丹。在通話中，您一直在管理式醫療方面遇到很多困難，您的 24 和 25 年合約進度如何？我知道你有很多國家合約。您看到了什麼樣的成長？對於該行業面臨的勞動力挑戰，您是否仍然會遇到一些增量衝擊，或者當您展望未來一兩年的利率時，它是否開始正常化？有什麼想法嗎？

A.J., this is actually Sun Park speaking on. Thanks for your question. And as I've slowly gotten to learn the business here, obviously, managed care is a critical component. Dan mentioned it as part of the tailwind that we do expect to continue to see into '24. And then as we've said historically, we do see commercial rate increases kind of mid-single digits. And I think more recently, we are seeing some rates at or at the high range of that. And I think that reflects the current inflationary environment that we're all seeing. So I think that's what we'll say.

A.J.，這實際上是 Sun Park 正在講話。謝謝你的提問。隨著我慢慢了解這裡的業務，管理式醫療顯然是關鍵組成部分。 Dan 提到這是我們預計 24 年將繼續看到的順風車的一部分。然後，正如我們歷史上所說，我們確實看到商業利率上漲了中個位數。我認為最近，我們看到一些利率處於或處於較高範圍。我認為這反映了我們所看到的當前通膨環境。所以我想這就是我們要說的。

Our next question today is coming from Jamie Perse from Goldman Sachs.

今天我們的下一個問題來自高盛的 Jamie Perse。

I'll add my congrats and thanks to Dan as well. My question is just on the labor environment. There were some headlines around some union contracts during the quarter, you mentioned it earlier. There's also the California minimum wage. Just wondering if you can give us an update on what you're seeing broadly with labor, if something structural has changed, if you're thinking about the next few years any different from rate of increase of labor? And then just if you can size anything on the California minimum wage in '24 and then '25 once that gets fully implemented.

我還要向丹表示祝賀和感謝。我的問題只是關於勞動環境。您之前提到過，本季度有一些關於一些工會合約的頭條新聞。還有加州的最低工資。只是想知道您是否可以向我們介紹一下您對勞動力的整體看法，結構性因素是否發生了變化，您對未來幾年勞動力增長率的看法是否有什麼不同？然後，如果你能在 24 年和 25 年全面實施加州最低工資標準的話，就可以了。

Yes, it's Saum. On the California minimum wage piece and the impacts of that, that was covered in Dan's commentary around headwinds. We haven't called out what it is specifically. We may do that in the future, but it was kind of covered within that broad category of headwinds. In terms of ongoing contract negotiations, I'm not going to comment on those, but we're obviously aware of them and deeply engaged in them. And I wouldn't say the environment has changed tremendously.

是的，是薩姆。關於加州最低工資及其影響，丹在有關逆風的評論中對此進行了闡述。我們還沒有說出具體是什麼。我們將來可能會這樣做，但這在某種程度上涵蓋了這個廣泛的逆風類別。就正在進行的合約談判而言，我不會對此發表評論，但我們顯然已經意識到它們並深入參與其中。我不會說環境發生了巨大變化。

I did note, we've worked on and settled 30 labor union contract negotiations relatively peacefully over the last couple of years, and we continue to work in good faith on all the contract negotiations we have. Obviously, there are things that complicate that environment in the middle of the wage bill in California being passed. But that's just something that we're going to work on with our employees and the union and we'll move past that at some point.

我確實注意到，在過去的幾年裡，我們已經相對和平地開展並解決了 30 項工會合約談判，並且我們將繼續真誠地進行所有合約談判。顯然，在加州工資法案通過期間，有些事情使環境變得複雜。但這只是我們將與員工和工會共同努力的事情，我們將在某個時候超越這一點。

Next question is coming from Calvin Sternick from JPMorgan.

下一個問題來自摩根大通的卡爾文·斯特尼克。

Is there any way to quantify how much capacity you've added so far this year? What the impact on volumes has been? And then going to next year when you talk about organic growth, how should we think about order of magnitude from further capacity expansions? And then any color on which markets or service lines are the biggest growth opportunities there? And when we think about California minimum wage, I mean, I think that should be manageable for you guys, but just wondering if that impacts how you think about the capacity expansions in those buckets.

有什麼方法可以量化今年到目前為止您增加了多少產能？對銷量有何影響？然後到明年，當您談論有機成長時，我們應該如何考慮進一步產能擴張的數量級？那麼哪些市場或服務線是最大的成長機會呢？當我們考慮加州的最低工資時，我的意思是，我認為這對你們來說應該是可以管理的，但只是想知道這是否會影響你們對這些領域產能擴張的看法。

Well, so there's a few different things to unpack in your question, but let me start with probably the most salient point around how we think about the hospital capacity. We're very cognizant of the service lines that we have prioritized market by market and maintain access for those service lines. And we have, even through this strategy of reducing our exposure or access, in some cases, in markets because of the contract labor expense. So through this year, I would say that we have maintained capacity or added a little bit back, but it has not been a significant change in our strategy this year with respect to managing contract labor. And by the way, the consequence of that is the contract labor reductions have been steady and progressive. And now the basis of them has changed from reducing capacity to succeeding in hiring and retention.

好吧，您的問題中有一些不同的內容需要解釋，但讓我從我們如何看待醫院容量的最突出的一點開始。我們非常了解我們按市場優先考慮的服務線，並保持這些服務線的准入。即使透過這種減少我們在市場中的暴露或進入的策略，在某些情況下，我們仍然會因為合約勞動力費用而減少。因此，今年以來，我想說我們保持了產能或增加了一點產能，但今年我們在管理合約工方面的策略並沒有發生重大變化。順便說一句，這樣做的結果是合約工的減少一直在穩步和逐步進行。現在，他們的基礎已經從減少產能轉變為成功招募和保留人才。

So that's -- and at the beginning of the year, I think we said the basis of the labor environment in '23 must change, in our view, towards hiring and retention away from capacity reduction. So we feel pretty good about having achieved that and selectively, as I noted, adding certain service lines -- that's why I try to highlight them in every quarterly update at 3 or 4 of our hospitals, service lines that we're adding, where we're adding that capacity and putting that investment to work in things that we believe we'll want to do.

所以，在今年年初，我認為我們說過，我們認為 23 年勞動力環境的基礎必須改變，轉向招募和保留，而不是減少產能。因此，我們對實現這一目標感到非常滿意，並且正如我所指出的，有選擇地添加某些服務項目- 這就是為什麼我嘗試在我們3 或4 家醫院的每個季度更新中強調它們，我們正在添加的服務項目，其中我們正在增加這種能力，並將投資投入到我們認為我們想做的事情中。

I don't know if -- I think the question was largely focused on the hospitals, but at USPI, we don't have as much of an impact of contract labor impacting our capacity. And so we have continued to expand access in centers across the country as the demand has risen. And the nice thing is that in a robust demand year, we've proven the ability to staff, staff it appropriately and maintain our margins with the growth that we have been able to deliver this year without creating a bunch of extraordinary expense in contract labor. So for USPI, I see the environment differently and we feel like this won't be as significant an issue going into 2024.

我不知道是否——我認為問題主要集中在醫院，但在 USPI，我們沒有受到合約工對我們能力的太大影響。因此，隨著需求的增加，我們繼續擴大全國各地中心的服務範圍。令人高興的是，在需求強勁的一年中，我們已經證明了我們有能力配備人員，配備適當的人員，並在今年實現增長的情況下保持我們的利潤，而不會在合約工方面產生大量異常費用。因此，對於 USPI 來說，我對環境的看法有所不同，我們認為這在 2024 年不會成為一個重要議題。

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。

And again, adding the thanks to Dan. It's a pleasure working with you for like all these years. On 2024 commentary, a quick clarification and a question. For clarification, if you take the midpoint of the guidance of $3.415 billion and pull out $10 million for Ramon and $14 million grant income and $34 million in cybersecurity, is $3.357 billion the right launchpad for 2024?

再次感謝丹。很高興與您一起工作這些年。關於 2024 年的評論，快速澄清和提問。澄清一下，如果你取34.15 億美元指引的中位數，為Ramon 拿出1000 萬美元、1400 萬美元的贈款收入和3400 萬美元的網路安全資金，那麼33.57 億美元是2024 年的正確啟動平台嗎？

And the question is, on the $100 million of headwinds you talked about, contract labor year-to-date is about $300 million. So if I add another $100 million in the fourth quarter, it's about [$400 million] of contract labor in 2023. The reduction in the last 2 quarters there have been about 28% or so. So while you aren't guiding for '24, could we think about contract labor settings -- contract labor savings offsetting those $100 million of headwinds you identified?

問題是，在你談到的 1 億美元的逆風中，今年迄今的合約工約為 3 億美元。因此，如果我在第四季度再增加 1 億美元，那麼到 2023 年，合約工的數量約為 [4 億美元]。過去兩季的減少量約為 28% 左右。因此，雖然您沒有為「24」提供指導，但我們是否可以考慮合約工設定——合約工節省額可以抵消您發現的 1 億美元的不利因素？

Pito, it's Dan. I'm not going to get into specifics in terms of the guidance for next year and what the launching point is. But we wanted to give you some high-level overview of those numbers. And again, roughly $100 million for the government funding type of reductions and the wage matter as well. And then grant income, you obviously see the grant income on a year-to-date basis of about $14 million and the cyber income year-to-date is about $34 million.

皮托，我是丹。我不會詳細說明明年的指導方針以及啟動點是什麼。但我們想為您提供這些數字的一些高級概述。同樣，大約 1 億美元用於政府資助類型的削減和工資問題。然後是贈款收入，您顯然會看到年初至今的贈款收入約為 1400 萬美元，而年初至今的網路收入約為 3400 萬美元。

And in terms of Q3 to Q4, as we mentioned a few minutes ago, when we think about the sequential walk from Q3 to Q4 for the hospitals as we talked about, we'll probably see some additional medical fees sequentially. And we're being cautious and when we think about contract labor in the fourth quarter and whether we need to potentially invest more to meet volume demands.

就第三季度到第四季度而言，正如我們幾分鐘前提到的，當我們考慮我們所討論的醫院從第三季度到第四季度的順序步行時，我們可能會依次看到一些額外的醫療費用。當我們考慮第四季度的合約工以及我們是否需要增加投資來滿足產量需求時，我們持謹慎態度。

Next question is coming from John Ransom from Raymond James.

下一個問題來自雷蒙德·詹姆斯的約翰·蘭塞姆。

On the hot topic in your sector but not for you, professional fees, could you just, in plain and simple English, tell us what professional fee expense looks like for calendar '23 in your guidance versus calendar '22?

關於您所在行業但不適合您的熱門話題，專業費用，您能否用簡單明了的英語告訴我們您的指導中日曆“23”與日曆“22”的專業費用費用是什麼樣的？

John, it's Dan. In terms of our medical fee costs so far this year, they're up around 15% compared to last year. And that's generally -- that's in line with what our expectations were this year. And basically, as we said a couple of times, we do anticipate some additional costs sequentially in Q4.

約翰，是丹。今年到目前為止我們的醫療費用比去年上漲了15%左右。總的來說，這符合我們今年的預期。基本上，正如我們多次說過的那樣，我們確實預計第四季度會出現一些額外成本。

Dan, is that the same number kind of 2 or 3 quarters up 15% or are you expecting it to be higher in the fourth quarter so making it higher for the year?

Dan，這個數字是 2 或 3 個季度增長 15% 的數字嗎？還是您預計第四季度會更高，因此今年會更高？

It would be -- we wouldn't anticipate going up from 15% in Q3 -- or sorry, Q4.

我們預計不會從第三季的 15% 上升，或抱歉，第四季。

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。

Apologies if I missed this earlier, but I was wondering if you could provide some commentary on growth, specifically within some of the USPI specialties, musculoskeletal and hips and knees, in particular, how that grew. And then all of the other specialties, I know you've made some investments in urology recently. Just how those -- if those areas are growing in line with your expectations?

如果我之前錯過了這一點，我深表歉意，但我想知道您是否可以提供一些關於生長的評論，特別是在USPI 的一些專業、肌肉骨骼、臀部和膝蓋方面，特別是它們是如何生長的。然後是所有其他專業，我知道您最近在泌尿科方面進行了一些投資。如果這些領域的成長符合您的預期，情況如何？

Yes. Hips and knees grew in the mid-teens over prior year -- year-over-year. And our collaboration and work with United Urology Group is growing faster than our expectations in terms of when the deal was done. And we continue to have attractive recovery in other areas like GI and ENT. So the growth is broad-based but the fastest growth is coming in joint surgeries.

是的。臀部和膝蓋比去年增長了十幾歲——逐年增長。就交易完成時而言，我們與聯合泌尿科集團的合作和工作的發展速度超出了我們的預期。我們在胃腸道和耳鼻喉科等其他領域繼續呈現有吸引力的復甦。因此，增長是廣泛的，但增長最快的是聯合手術。

Next question is coming from Jason Cassorla from Citigroup.

下一個問題來自花旗集團的 Jason Cassorla。

I just wanted to ask about the updated USPI guidance. Just curious on the margins. You have the ranges out there but the midpoint would suggest slightly lower margins versus where you previously were, stronger revenue than EBITDA dollars. I guess, can you give us an idea on how you're seeing margin progression from the newer de novos and M&A you've done over the past 12 months, maybe against the margin headwinds but bigger gross profit dollars that come with higher acuity cases as you focus growth there? Just any help there would be great. Would appreciate it.

我只是想問一下更新的 USPI 指南。只是對邊緣感到好奇。你有這些範圍，但中點顯示利潤率比之前的水平略低，收入比 EBITDA 更強。我想，您能否告訴我們，您如何看待過去12 個月中進行的新的從頭交易和併購中的利潤增長，也許是在克服利潤逆風的情況下，但隨著案例敏銳度的提高，毛利潤也會增加當你專注於那裡的成長時？任何幫助都會很棒。會很感激的。

Well, yes, let me make a couple of comments just contextually. I mean, one is, we work to maintain our USPI margins based upon longer-term business decisions we make around service lines that we choose to be in, what we think the mix will be with the physicians that we work with, et cetera. But make no mistake about it. There are many things that we could do to grow the business within that range that may move the margins up or sometimes down a bit, but they're still highly accretive to the business, given the types of post-synergy multiples that we deliver. So I just want to provide that backdrop because we focus on a range that we want to be in for the ROIs that we want to have.

嗯，是的，讓我根據上下文發表一些評論。我的意思是，一是，我們努力維持我們的 USPI 利潤，這是基於我們圍繞我們選擇的服務線做出的長期業務決策、我們認為與我們合作的醫生的組合等等。但請不要誤會。為了在這個範圍內發展業務，我們可以採取很多措施，這些措施可能會提高利潤率，有時甚至會降低一點，但考慮到我們提供的協同後倍數的類型，它們仍然對業務具有很高的增值作用。所以我只想提供這個背景，因為我們專注於我們想要獲得的投資報酬率的範圍。

Now specifically to your question around service lines, remember, the government mix in different service lines can be different. And obviously, the government mix will have a lower margin. That doesn't necessarily mean that avoiding the service lines that have a little bit more government mix, like for example, joint replacements or other orthopedic-type procedures is the right answer because they add net revenue intensity. But when those service lines scale up to their full potential, they meet USPI's margins, right? So when you're scaling up a new service line and you're running at subscale in 60, 70 centers as you introduce ortho into those centers, of course, the margins will be lower until you get them up to scale.

現在具體針對您有關服務領域的問題，請記住，不同服務領域的政府組合可能有所不同。顯然，政府組合的利潤率將會較低。這並不一定意味著避免政府混合更多的服務項目（例如關節置換或其他骨科類型手術）是正確的答案，因為它們增加了淨收入強度。但當這些服務線充分發揮其潛力時，它們就會達到 USPI 的利潤，對吧？因此，當您擴大新的服務線並在 60、70 個中心以小規模運行時，當您將正交引入這些中心時，當然，利潤會較低，直到您擴大規模為止。

And you're finally correct to point out that as we increase the number of de novos, obviously, those are operating expenses that are, in our environment, not contributing to the revenue and margin profile of existing centers. And as we've moved from having a handful 3 or 4 de novos to 30, we are obviously cognizant of the fact that we need to overcome those operating expenses to maintain the margins that we've outlined in our range. And the good news is we're doing that. We don't talk about it much because it has not been an issue.

您最終正確地指出，隨著我們增加從頭數量，顯然，這些營運費用在我們的環境中對現有中心的收入和利潤狀況沒有貢獻。隨著我們從擁有 3 或 4 個新工廠發展到 30 個，我們顯然認識到我們需要克服這些營運費用以維持我們在我們的範圍內概述的利潤率。好消息是我們正在這樣做。我們不多談論它，因為這不是一個問題。

Yes, Jason, the USPI's full year margin for this year is roughly 40%, 39.8%, that's where we're guiding to. In the fourth quarter, we're assuming the margin is close to 43%, 42.8%. So the margins are incredibly strong at USPI and the business is performing well.

是的，Jason，USPI 今年的全年利潤率約為 40%、39.8%，這就是我們的指導目標。在第四季度，我們假設利潤率接近 43%、42.8%。因此，USPI 的利潤率非常高，而且業務表現良好。

Next question is coming from Brian Tanquilut from Jefferies.

下一個問題來自 Jefferies 的 Brian Tanquilut。

Dan, thanks again for all the help over the years. I guess my question, as I think about your comment about medical fees being up sequentially, is that just conservatism or expectations for higher volume? And then maybe for Saum, maybe take a step back, how do you think or judge to make that decision to in-source certain physician groups versus keeping them third party?

丹，再次感謝多年來的所有幫助。當我想到你對醫療費用連續上漲的評論時，我想我的問題是，這只是保守主義還是對更高數量的期望？然後，也許對於索姆來說，也許退後一步，您如何看待或判斷做出內包某些醫生團體而不是讓他們成為第三方的決定？

Just on the first point, I'm not sure I would characterize -- look, the way I would characterize it is what I've said all along this year, which is we are interested in seeing what a fourth quarter looks like post pandemic for the first time in many years. You can interpret that as how you want to from your question around conservatism or whatnot. We're being thoughtful in our view about the services that we want to offer and maintain access to as we move into the fourth quarter, and we're doing it in a way in which we would like to maintain strong margins.

就第一點而言，我不確定我會描述——看，我描述它的方式就是我今年一直所說的，那就是我們有興趣看看大流行後第四季度的情況多年來第一次。你可以將其解釋為你想要如何從你關於保守主義或其他什麼的問題中得到答案。當我們進入第四季度時，我們對我們想要提供和保持訪問的服務的看法是深思熟慮的，我們正在以一種我們希望保持強勁利潤的方式來做這件事。

Now I'll point out again, I did it in the very first couple of lines of my statement at the beginning of the earnings call. It's notable that we are reaching the point where we're almost at a 17% EBITDA margin company-wide. We believe in the strategy we're pursuing around acuity, capital efficiency, thoughtful management of our capacity for the services we offer and obviously the expansion and growth of USPI. And that margin is notable for Tenet as an entity, which I don't think we've seen for a very long time, if ever. So that's really the pathway we're down. There was a second part of your question which I didn't take down.

現在我要再次指出，我在財報電話會議開始時的聲明的前幾行中就做到了這一點。值得注意的是，我們全公司的 EBITDA 利潤率幾乎達到了 17%。我們相信我們所追求的策略是敏銳的、資本效率的、對我們提供的服務能力的周到管理，當然還有 USPI 的擴張和成長。對於特尼特作為一個實體來說，這種利潤是值得注意的，我認為我們已經很久沒有看到這種情況了，如果有的話。所以這確實是我們所走的路。你問題的第二部分我沒有記下來。

It was in terms of the sequential increase that we're assuming from 3 to 4 in medical fees. I mean, some of it also relates to, it can be a combination of volume. It can be a combination of contracts we've entered into that we know how the pricing lies out.

就環比增長而言，我們假設醫療費用從 3 增加到 4。我的意思是，其中一些也與體積有關。它可以是我們已經簽訂的合約的組合，我們知道定價是如何決定的。

Yes. And to your question about in-source/outsource, I mean, our managed care contracting platform is pretty thorough. I mean, we talk about what we do with respect to hospitals and ambulatory surgery centers and other things. But we do maintain active physician service contracts for hospital-based specialties. And we do have markets in which we have, over the last couple of years, in-sourced, outsourced -- previously outsourced work.

是的。對於您有關內源/外包的問題，我的意思是，我們的管理式醫療承包平台非常全面。我的意思是，我們談論我們在醫院和門診手術中心以及其他方面所做的事情。但我們確實與醫院專科保持有效的醫生服務合約。在過去的幾年裡，我們確實有一些市場，在這些市場中，我們進行了內包、外包——以前的外包工作。

Again, I would refer you to even back during the pandemic, I made some comments about the fact that we undertook a comprehensive review of every physician service contract in the company to restructure, consolidate, scale services and work with some of our better partners. And when those weren't available either due to market penetration issues or competitive issues they may have had, we looked at opportunities to in-source. So we understand that these fees are going up. But all year long and going into next year, we're planning them in the way we issue guidance.

再次，我想請您參考一下，即使在大流行期間，我也對我們對公司的每一份醫生服務合約進行了全面審查以重組、整合、擴展服務並與我們一些更好的合作夥伴合作這一事實發表了一些評論。當由於市場滲透問題或可能存在的競爭問題而無法獲得這些資源時，我們就會尋找內源的機會。所以我們知道這些費用正在上漲。但從全年到明年，我們都在以發布指導的方式進行規劃。

Our final question today is coming from Sarah James from Cantor Fitzgerald.

我們今天的最後一個問題來自康托·菲茨杰拉德的莎拉·詹姆斯。

I want to echo my well wishes to Dan. I appreciate the comment that you just made about the service contract review, but I think also during the pandemic, Tenet stood out in making investments in technology for efficiency and scheduling. So I'm wondering, has that had any impact on your mix of contracted physician labor? And then also, are you seeing any of the incremental pushback on inpatient versus monitoring clarification that some of your peers are in acute?

我想向丹轉達我的良好祝愿。我很欣賞你剛才對服務合約審查的評論，但我認為在大流行期間，Tenet 在提高效率和調度方面的技術投資方面也表現出色。所以我想知道，這對你們的合約醫生勞動力組合有什麼影響嗎？另外，您是否看到住院患者與監測澄清方面有任何漸進的阻力，表明您的一些同行處於急性狀態？

Yes. So on the technology front, I appreciate you remembering that. I mean, we deployed technologies that assist with scheduling in most of our high acuity like surgical, cath lab, other procedure areas, along with some interesting things that we did even in emergency room access for lower acuity scheduled but truly emergent care. And those have been paying off well.

是的。所以在技術方面，我很感謝你記住這一點。我的意思是，我們部署了一些技術來協助安排大多數高危急區域（如外科手術、導管實驗室、其他手術區域），以及我們甚至在急診室進行的一些有趣的事情，以實現危急程度較低但真正緊急的護理。這些都得到了很好的回報。

We've also continued to utilize scheduling technologies in our outpatient specialty practices. And one of the reasons we do that is it gives us the ability in a data-driven way to track week-to-week volume demand movements in our specialty practices, which we roll up countrywide to understand what's going on in the different specialties because the technology provides an automated source of having that data. So yes, I mean, we feel good about those investments. They were not large investments. They're simple, usable technologies that are physician-friendly and we feel pretty good about those.

我們也繼續在門診專業實踐中利用調度技術。我們這樣做的原因之一是，它使我們能夠以數據驅動的方式追蹤我們的專業實踐中每週的需求量變化，我們在全國範圍內進行滾動以了解不同專業的情況，因為該技術提供了取得該數據的自動化來源。所以，是的，我的意思是，我們對這些投資感覺很好。這些投資規模並不大。它們是簡單、可用且對醫生友好的技術，我們對此感覺非常好。

In terms of inpatient/outpatient pressure, I would reframe that into -- we are concerned with the degree of denial activity that we see from some of the health plans. We think it's excessive and inappropriate. And we continue to work on our appropriate documentation, both for us and obviously with Conifer for all of our clients in order to push back on the volume of clinical denials on the basis of having excellent documentation. And we think that's the right path out of that.

就住院/門診壓力而言，我將其重新定義為——我們專注於從一些健康計劃中看到的拒絕活動的程度。我們認為這是過度且不恰當的。我們繼續為我們自己以及 Conifer 為我們所有的客戶制定適當的文件，以便在擁有優秀文件的基礎上減少臨床拒絕的數量。我們認為這是解決這個問題的正確方法。

We reached the end of our question-and-answer session. I'd like to turn the floor back over to Saum for any further or closing comments.

我們的問答環節結束了。我想將發言權交還給索姆，以徵求進一步的意見或結束意見。

Yes. So Justin stole my thunder but I kept this until the end because I was worried Dan might walk out if we thank him too early from this phone call. But I want to thank Dan as well not only for being an outstanding CFO, an exceptional colleague. But I would tell you, he is the picture of integrity and honesty that's a role model for every CFO that exists in this country. So thank you, Dan.

是的。所以賈斯汀搶了我的風頭，但我把這句話保留到最後，因為我擔心如果我們太早在電話中感謝他，丹可能會離開。但我還要感謝 Dan，他不僅是一位出色的財務官，也是一位傑出的同事。但我想告訴你，他是正直和誠實的典範，是這個國家每一位財務長的榜樣。所以謝謝你，丹。

Appreciate the kind remarks, Saum.

感謝您的善意評論，索姆。

All right. With that, we'll wrap up. Thank you, everybody.

好的。至此，我們就結束了。謝謝大家。

That does conclude today's teleconference and webcast. You may disconnect your line at this time, and have a wonderful day. We thank you for your participation today.

今天的電話會議和網路廣播到此結束。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。