Tenet Healthcare Corp (THC) 2023 Q4 法說會逐字稿

Good morning. Welcome to Tenet Healthcare's Fourth Quarter 2023 Earnings Conference Call. (Operator Instructions)

早安.歡迎參加 Tenet Healthcare 2023 年第四季財報電話會議。 （操作員說明）

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

現在我將把電話轉交給東道主投資者關係副總裁威爾麥克道爾 (Will McDowell) 先生。麥克道爾先生，您可以開始了。

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

大家早安，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 年第四季的業績以及我們的財務前景。

Tenet's senior management participating in today's call will be Dr. Saum Sutaria, Chairman and Chief Executive Officer; and Sun Park, Executive Vice President and Chief Financial Officer.

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；執行副總裁兼財務長 Sun Park。

Our webcast this morning 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.

今天早上我們的網路廣播包括一個幻燈片演示，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 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.

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。

One item that I would like to bring your attention related to our disclosures is a change in our segment reporting. Effective in the fourth quarter of 2023, we have combined Conifer and the Hospital Operations into one reportable operating segment, Hospital Operations and Services. This change was made to reflect recent updates to the organizational and management structure of Conifer and Hospital Operations. This change has no impact on Tenet's consolidated revenues, EBITDA, net income, margins or cash flows. The Conifer business will continue to support and expand relationships with existing clients, and generate new business both for comprehensive end-to-end services, endpoint solutions.

我想提請您注意與我們的揭露相關的一項內容是我們分部報告的變更。自 2023 年第四季起，我們已將 Conifer 和醫院營運部門合併為一個可報告營運部門：醫院營運和服務部門。做出這項變更是為了反映針葉樹和醫院營運組織和管理結構的最新更新。這項變更對 Tenet 的合併收入、EBITDA、淨利潤、利潤率或現金流沒有影響。 Conifer 業務將繼續支援和擴大與現有客戶的關係，並為全面的端到端服務和端點解決方案創造新業務。

To ease the transition for investors and analysts, we have included historical financial information under the new segment reporting structure on Page 4 of our fourth quarter 2023 financial supplement.

為了方便投資者和分析師進行過渡，我們在 2023 年第四季財務補充報告的第 4 頁上納入了新分部報告架構下的歷史財務資訊。

And with that, I turn the call over to Saum.

說完，我把電話轉給了 Saum。

Thank you, Will, and good morning, everyone. 2023 was an exceptional year for Tenet, we recorded net operating revenues of $20.5 billion, and consolidated adjusted EBITDA of $3.54 billion, which translates into an attractive 17.2% adjusted EBITDA margin, underscoring our ability to drive profitability while maintaining our commitment to quality and innovation. We finished the year strong and delivered results in the fourth quarter that were well above the expectations we set. This was driven by continued volume strength as well as cost and utilization management.

謝謝你，威爾，大家早安。 2023 年對Tenet 來說是不平凡的一年，我們錄得淨營業收入205 億美元，綜合調整後EBITDA 為35.4 億美元，調整後EBITDA 利潤率為17.2%，極具吸引力，這突顯了我們在保持對品質和創新的承諾的同時提高盈利能力的能力。我們強勁地結束了這一年，第四季的業績遠高於我們設定的預期。這是由持續的銷售成長以及成本和利用率管理所推動的。

Each quarter in 2023, we exceeded our performance expectations. As important as our performance in 2023, we advanced our business transformation towards a more profitable value-based care enterprise, building a leading specialty care platform and furthering our corporate priorities to position us with lower leverage and enhanced free cash flow opportunities looking forward.

2023 年每個季度，我們的業績都超出了預期。與我們2023 年的業績同樣重要的是，我們推動業務轉型，成為一家盈利能力更強的基於價值的護理企業，建立領先的專業護理平台，並進一步推進我們的企業優先事項，使我們能夠在未來獲得更低的槓桿率和更多的自由現金流機會。

Let's start with USPI, where we had a phenomenal 2023, a year where we finally escaped COVID disruption to the business. USPI generated $1.54 billion in EBITDA, which represented 16.4% growth over 2022 and margins of 40%. USPI had 9.2% growth in same-facility revenues in 2023, substantially above our long-term goal of 4% to 6% top line growth. Joint replacement surgeries were up nearly 20% in the fourth quarter and over 15% for the year.

讓我們從 USPI 開始，我們在 2023 年經歷了非凡的一年，這一年我們終於擺脫了新冠疫情對業務的干擾。 USPI 產生 15.4 億美元的 EBITDA，較 2022 年成長 16.4%，利潤率為 40%。 2023 年，USPI 的同設施收入成長 9.2%，遠高於我們 4% 至 6% 營收成長的長期目標。第四季關節置換手術成長了近 20%，全年成長超過 15%。

Throughout the year, we saw ongoing strength and recovery in GI, urology and ENT procedures. This organic growth was driven by continued expansion of service lines and growth in our population of partnered and affiliated physicians as well as the fundamental tailwinds of patient demand for safe and convenient surgical care options.

在這一年裡，我們看到胃腸道、泌尿科和耳鼻喉科手術不斷增強和恢復。這種有機增長是由服務線的持續擴大、合作醫生和附屬醫生人數的增長以及患者對安全、方便的手術護理選擇的需求的基本推動因素所推動的。

In 2023, we added 30 centers to the portfolio, furthering our goal of creating additional lower-cost sites of care for patients and physicians while delivering superior value for our stakeholders.

2023 年，我們在產品組合中新增了 30 個中心，進一步推進了我們為患者和醫生創建更多低成本護理場所的目標，同時為我們的利害關係人提供卓越的價值。

Turning to our hospital segment. We generated $2 billion of adjusted EBITDA in 2023, which represents a 12% EBITDA margin. Acuity remains strong, with fourth quarter 2023 revenue per adjusted admission up 6.5% over prior year.

轉向我們的醫院部門。 2023 年，我們產生了 20 億美元的調整後 EBITDA，即 12% 的 EBITDA 利潤率。 Acuity 依然強勁，2023 年第四季調整後的入場收入比去年同期成長 6.5%。

Additionally, non-COVID same-store inpatient admissions were up 2.6% in the quarter and 6.2% for all of 2023.

此外，本季非新冠肺炎同店住院人數增加了 2.6%，2023 年全年成長了 6.2%。

Our investments in nurse recruitment and retention have paid dividends as we have strengthened our workforce and effectively reduced contract labor spend throughout the year. By the fourth quarter of 2023, contract labor accounted for just 2.8% of consolidated salaries, wages and benefits, a 62% reduction from fourth quarter 2022. This best-in-class contract labor cost management performance helped drive strong results in '23, and we expect to continue to benefit from our operational discipline in the future.

我們在護理師招募和留任方面的投資已獲得回報，因為我們增強了勞動力並有效減少了全年的合約勞動力支出。到 2023 年第四季度，合約工僅佔綜合薪資、薪資和福利的 2.8%，比 2022 年第四季減少 62%。這種一流的合約工成本管理績效幫助推動了 23 年的強勁業績。我們預計未來將繼續受益於我們的營運紀律。

In summary, we are very pleased with the performance of our teams in 2023, and believe that we will carry the momentum into the new year.

總而言之，我們對2023年團隊的表現感到非常滿意，相信我們將把這種勢頭帶入新的一年。

Let me transition to 2024 guidance. We are projecting full year 2024 adjusted EBITDA of $3.825 (sic) [$3.285] billion to $3.485 billion, which is an attractive 7% growth rate at the midpoint on a normalized basis.

讓我過渡到 2024 年指導。我們預計 2024 年全年調整後 EBITDA 為 3.825 美元（原文如此）[32.85 美元] 至 34.85 億美元，按標準化計算，中點增長率為 7%，頗具吸引力。

In addition, during our third quarter earnings call, we said that we would overcome various reimbursement headwinds to grow EBITDA in 2024, which this guidance reflects.

此外，在第三季財報電話會議上，我們表示，我們將克服各種報銷阻力，在 2024 年實現 EBITDA 成長，這項指引也反映了這一點。

First, in our industry-leading ambulatory surgery business, we anticipate adjusted EBITDA growth of approximately 9% at the midpoint of our guidance in 2024, based on our expectations of ongoing strength in demand coupled with great visibility into our pricing, 3% to 6% growth in same-facility revenue, continuous improvement in our operating efficiency and additional sites of care joining the portfolio.

首先，在我們行業領先的門診手術業務中，基於我們對需求持續強勁的預期以及對我們定價的高度可見性，我們預計 2024 年調整後 EBITDA 增長約為 9%（3% 至 6%）。相同設施收入的成長百分比、我們營運效率的持續改善以及更多護理場所加入投資組合。

As we have noted, we believe that in 2023, we saw recovery in demand that included some impact from deferred volume, particularly in GI and ENT services. Our initial assumption for volume growth assumes that volume will build as the year progresses, reflecting the historically high same-store case growth that we saw in the first quarter of 2023. We are very confident in the long-term growth rates of this business.

正如我們所指出的，我們認為，到 2023 年，我們會看到需求復甦，其中包括延期數量的一些影響，特別是在胃腸道和耳鼻喉服務領域。我們對銷售成長的初步假設是銷量將隨著時間的推移而增加，這反映了我們在 2023 年第一季看到的歷史最高同店案例成長。我們對該業務的長期成長率非常有信心。

USPI will continue its commitment to expanding its family of lower-cost ambulatory surgery centers. We've consistently acquired centers at attractive valuations and achieved post-synergy multiples to below 5x, while improving our quality and delivering a 96.6% overall patient experience score under our management. We intend to invest approximately $200 million to $250 million each year and have a robust pipeline to support that level of investment.

USPI 將繼續致力於擴大其低成本門診手術中心系列。我們一直以有吸引力的估值收購中心，並將協同後的倍數實現到 5 倍以下，同時提高我們的質量，並在我們的管理下提供 96.6% 的整體患者體驗評分。我們打算每年投資約 2 億至 2.5 億美元，並擁有強大的管道來支持這項投資水準。

We also have a healthy de novo development pipeline of more than 30 centers currently in the syndication stages or under construction. We believe adding centers with strong margins and attractive post-synergy multiples remains the most effective use of our cash for investments to enhance Tenet's earnings and free cash flow.

我們還擁有健康的從頭開發管道，其中 30 多個中心目前處於聯合階段或正在建設中。我們相信，增加利潤豐厚且具有吸引力的協同後倍數的中心仍然是我們現金投資的最有效利用方式，以提高特尼特的盈利和自由現金流。

Turning to our Hospital segment. We are expecting adjusted EBITDA growth of approximately 5% on a normalized basis at the midpoint for 2024. This projected growth is expected to be driven by 1% to 3% adjusted admissions growth and continued operating discipline.

轉向我們的醫院部分。我們預計 2024 年中點調整後 EBITDA 在標準化基礎上成長約 5%。這一預計成長預計將由 1% 至 3% 的調整後招生成長和持續的營運紀律推動。

Having captured much of the value from contract labor rationalization last year, in 2024, we plan to continue to strategically open up capacity to meet growing demand in a number of our markets, leveraging our previous capital investments.

去年，我們從合約工合理化中獲得了大部分價值，到 2024 年，我們計劃利用先前的資本投資，繼續策略性地開放產能，以滿足多個市場不斷增長的需求。

Additionally, our hospitals continue to enhance access to higher acuity services for the benefits of our patients and communities that we serve.

此外，我們的醫院也持續加強獲得更高敏銳度服務的機會，以造福我們的病人和我們所服務的社區。

For example, our Abrazo Arrowhead hospital just opened its new neonatal intensive care unit, this state-of-the-art expansion increases our bed capacity to support services for preterm babies and high-risk pregnancies by 75% at this facility. We are also particularly excited about the progress of our new Westover Hills Hospital in San Antonio, a project that reflects our strategic and disciplined approach to expansion. We expect that this facility will be completed and begin to serve patients in the second half of 2024. Located in a highly attractive and growing market, Westover Hills is another example of our thoughtful expansion strategy that we have been executing for a number of years. This 100-bed facility will focus on higher acuity services, such as cardiovascular and surgical care for the people in that community.

例如，我們的 Abrazo Arrowhead 醫院剛剛開設了新的新生兒重症監護病房，這一最先進的擴建將我們的床位容量增加了 75%，以支持該設施為早產兒和高危險妊娠提供的服務。我們也對聖安東尼奧新 Westover Hills 醫院的進展感到特別興奮，該計畫反映了我們策略性和嚴格的擴張方法。我們預計該設施將於 2024 年下半年竣工並開始為患者提供服務。Westover Hills 位於一個極具吸引力且不斷增長的市場，是我們多年來一直執行的深思熟慮的擴張戰略的另一個例子。這個擁有 100 個床位的設施將專注於為該社區的人們提供更高敏銳度的服務，例如心血管和外科護理。

Finally, Conifer recently announced the continuation of our partnership with Dartmouth Health through a new multiyear agreement. Conifer will continue to serve as the exclusive provider of end-to-end revenue cycle management services for Dartmouth Health hospitals, physician services and other related entities. We also added a new partnership with Conifer's value-based care business unit, which will be providing analytics and operational support services for capitated risk arrangements.

最後，Conifer 最近宣布透過一項新的多年協議繼續與達特茅斯健康中心合作。 Conifer 將繼續作為達特茅斯健康醫院、醫生服務和其他相關實體的端到端收入週期管理服務的獨家提供者。我們還與 Conifer 的基於價值的護理業務部門建立了新的合作夥伴關係，該部門將為按人頭安排的風險安排提供分析和營運支援服務。

All in all, our full year 2024 adjusted EBITDA guidance of $3.285 billion to $3.485 billion, represents attractive growth following a very successful 2023.

總而言之，我們的 2024 年全年調整後 EBITDA 指引為 32.85 億美元至 34.85 億美元，代表著繼 2023 年非常成功之後的有吸引力的成長。

Before I turn the call over to Sun, I'd like to highlight the continued progress that we have made transforming our portfolio of businesses. Building upon the highly successful and accretive sale of the Miami Hospital in 2021, in the past few months, we have announced the following transactions that demonstrate our agility in optimizing our businesses.

在將電話轉給 Sun 之前，我想強調一下我們在業務組合轉型方面所取得的持續進展。在 2021 年邁阿密醫院銷售取得巨大成功和增值的基礎上，在過去的幾個月裡，我們宣布了以下交易，這些交易證明了我們在優化業務方面的敏捷性。

First, the completed $2.4 billion sale of 3 coastal South Carolina hospitals and expansion of our Conifer services to Novant Health. Next, the formation of a joint venture with [NextCare], which operates dozens of high-quality urgent care locations and a telehealth operation in Arizona. This immediately increases patient access to our network in this geography with low-cost sites of care that are complementary to our health system footprint.

首先，以 24 億美元完成了南卡羅來納州 3 家沿海醫院的出售，並將我們的 Conifer 服務擴展到 Novant Health。接下來，與 [NextCare] 成立一家合資企業，在亞利桑那州經營數十個高品質的緊急護理地點和遠距醫療業務。這立即增加了患者在該地區訪問我們網絡的機會，透過低成本的護理站點來補充我們的醫療系統足跡。

And finally, the $975 million sale of 4 hospitals and related operations in Orange County and L.A. County to UCI Health that we expect to close in the spring of 2024, subject to customary regulatory approvals, clearances and closing conditions. This deal will also include a contract for Conifer services.

最後，以9.75 億美元的價格向UCI Health 出售奧蘭治縣和洛杉磯縣的4 家醫院及相關業務，我們預計該交易將於2024 年春季完成，但須獲得慣例的監管批准、許可和成交條件。該交易還將包括一份針葉樹服務合約。

It is important to note that these sales were completed at very attractive EBITDA multiples, evidencing the strength of our assets and the quality of care they provide in their communities. Collectively, these transactions will substantially improve our leverage position.

值得注意的是，這些銷售是以非常有吸引力的 EBITDA 倍數完成的，證明了我們的資產實力以及他們在社區中提供的護理品質。總的來說，這些交易將大大改善我們的槓桿狀況。

On a pro forma basis, proceeds from these recent transactions have the potential to lower our leverage ratios by approximately 0.6 turns, resulting in a debt-to-EBITDA ratio of approximately 3.3x or 4.2x on an EBITDA minus NCI basis. This is on top of post-tax proceeds of $1.1 billion from our Miami Hospital transaction in 2021 that we used to pay down debt.

根據預計，這些近期交易的收益有可能將我們的槓桿率降低約 0.6 倍，從而使債務與 EBITDA 的比率約為 3.3 倍或 4.2 倍（以 EBITDA 減去 NCI 計算）。除此之外，我們也利用 2021 年邁阿密醫院交易獲得的 11 億美元稅後收益來償還債務。

Tenet is entering a new era, with a greater proportion of our performance coming from our highly efficient ambulatory surgical business and a reduced debt profile, we are well positioned to continue to expand free cash flow further over time. We are mindful of what got us here in the last 5 years, operating excellence, disciplined capital allocation with a focus on ROIC, an analytics-driven culture and a continuous improvement mindset. As a result, we will have significant financial and capital flexibility to increase shareholder value over the long term.

特尼特正在進入一個新時代，我們的業績的更大比例來自我們高效的門診手術業務和債務狀況的減少，我們有能力隨著時間的推移繼續進一步擴大自由現金流。我們牢記過去 5 年裡我們取得今天成就的原因：卓越營運、注重投資回報率的嚴格資本配置、分析驅動的文化和持續改進的心態。因此，我們將擁有顯著的財務和資本靈活性，以長期增加股東價值。

And with that, I will turn the call over to Sun to provide a more detailed review of our financial results and 2024 guidance. Sun?

接下來，我將把電話轉給 Sun，以對我們的財務表現和 2024 年指導進行更詳細的審查。太陽？

Thank you, Saum, and good morning, everyone. We are very pleased with the strong finish of our fiscal 2023, with fourth quarter adjusted EBITDA coming in well above the high end of our most recent guidance ranges for both the USPI and the Hospital Segments.

謝謝你，索姆，大家早安。我們對 2023 財年的強勁業績感到非常滿意，第四季度調整後 EBITDA 遠高於我們 USPI 和醫院部門最新指導範圍的上限。

In the fourth quarter, we generated total net operating revenues of $5.4 billion and consolidated adjusted EBITDA of $1.012 billion. For full year '23, we generated $20.5 billion of total net operating revenues and consolidated adjusted EBITDA of $3.54 billion. These results were driven by strong growth in USPI same-store volumes and net revenue per case, strong patient acuity and overall revenue growth in the hospitals and very effective expense controls throughout the businesses, with the management of contract labor costs as a notable example.

第四季度，我們實現了 54 億美元的總淨營運收入，調整後的綜合 EBITDA 為 10.12 億美元。 2023 年全年，我們實現了 205 億美元的總淨營業收入，調整後的綜合 EBITDA 為 35.4 億美元。這些結果的推動因素包括USPI 同店銷售和每例淨收入的強勁增長、醫院患者的敏銳度和整體收入的強勁增長以及整個企業非常有效的費用控制，其中合同勞動力成本的管理就是一個顯著的例子。

Now I'd like to highlight some key items for each of our segments, beginning with USPI, which again delivered strong operating results in the fourth quarter. USPI's fourth quarter adjusted EBITDA grew 14% compared to last year, and its adjusted EBITDA margin continues to be very strong at 43%. USPI delivered a 9.5% increase in same-facility system-wide revenues compared to fourth quarter of '22, with same-facility system-wide surgical case volume up by 3.9% and net revenue per case up 5.4%.

現在我想強調我們每個部門的一些關鍵項目，首先是 USPI，它在第四季度再次帶來了強勁的營運業績。 USPI 第四季度調整後 EBITDA 與去年同期相比增長了 14%，調整後 EBITDA 利潤率繼續保持在 43% 的強勁水平。與 2022 年第四季相比，USPI 的同設施全系統營收成長了 9.5%，同設施全系統手術病例數成長了 3.9%，每例淨收入成長了 5.4%。

Turning to our Hospital Segment. Fourth quarter same hospital inpatient admissions increased 1%, with non-COVID inpatient admissions up 2.6%. Revenue per adjusted admissions grew 6.5%, demonstrating strong payer mix and continued high acuity levels. Our fourth quarter results also reflect $52 million of favorable adjustments associated with Medicaid supplemental revenue programs in California and Texas.

轉向我們的醫院部門。第四季同一醫院的住院人數增加了 1%，其中非新冠肺炎住院人數增加了 2.6%。調整後的每次入場收入增長了 6.5%，顯示了強大的付費者組合和持續的高敏銳度。我們第四季的業績也反映出與加州和德州醫療補助補充收入計畫相關的 5,200 萬美元的有利調整。

In terms of strong expense management, our consolidated SWB was 43% of net revenues in the fourth quarter which was substantially lower than the 46.2% we saw in fourth quarter of '22, and our consolidated contract labor rate was 2.8% of SWB, a material reduction from 7.3% in the fourth quarter of '22.

在強有力的費用管理方面，我們的綜合SWB 在第四季度佔淨收入的43%，大大低於我們在2022 年第四季看到的46.2%，而我們的綜合合約工率為SWB 的2.8% ，材料從 22 年第四季的 7.3% 減少。

On a per adjusted admission basis, fourth quarter hospital SWB was 160 basis points lower than fourth quarter '22. These reductions over the course of the year reflect the disciplined approach that we take towards labor management. And finally, fourth quarter medical fees were up $16 million sequentially, and $40 million higher than fourth quarter of '22, consistent with our expectations. Overall, these costs were up about 15% for full year 2023.

以調整後的入院標準計算，第四季醫院 SWB 比 2022 年第四季低 160 個基點。一年中的這些減少反映了我們對勞動力管理的嚴格方法。最後，第四季的醫療費用比上一季增加了 1,600 萬美元，比 2022 年第四季增加了 4,000 萬美元，這與我們的預期一致。總體而言，2023 年全年這些成本增加了約 15%。

Next, we will discuss our cash flow, balance sheet and capital structure. Our cash flow performance was very strong in 2023, with $1.6 billion of free cash flow for the year. We finished the year with over $1.2 billion of cash, with no borrowings outstanding under our $1.5 billion line of credit facility.

接下來，我們將討論我們的現金流量、資產負債表和資本結構。 2023 年，我們的現金流表現非常強勁，全年自由現金流為 16 億美元。年底，我們擁有超過 12 億美元的現金，15 億美元的信貸額度下沒有未償還的借款。

During the fourth quarter, we repurchased 1.6 million shares of our stock for $110 million, and for full year '23, we repurchased 3.1 million shares of our stock for $200 million. Our year-end 2023 leverage ratio was 3.89x EBITDA or 4.85x EBITDA less NCI. It is important to note that these ratios do not reflect the $2.55 billion in after-tax proceeds and $190 million of associated tax benefits from our announced divestitures, which collectively will support our goals to deleverage the balance sheet.

在第四季度，我們以 1.1 億美元回購了 160 萬股股票，在 23 年全年，我們以 2 億美元回購了 310 萬股股票。 2023 年底，我們的槓桿率為 3.89 倍 EBITDA，或 4.85 倍 EBITDA 減去 NCI。值得注意的是，這些比率並未反映我們宣布的資產剝離帶來的 25.5 億美元稅後收益和 1.9 億美元的相關稅收優惠，這些收益共同將支持我們去槓桿化資產負債表的目標。

Also, as of year-end 2023, we have no significant debt maturities until the first quarter of 2026, and all of our outstanding senior secured and unsecured notes have fixed interest rates.

此外，截至 2023 年底，我們在 2026 年第一季之前沒有重大債務到期，且我們所有未償還的優先有擔保和無擔保票據都有固定利率。

In the aggregate, we believe we have significant financial flexibility and cash flow generation to support our capital allocation priorities.

總的來說，我們相信我們擁有顯著的財務靈活性和現金流量產生來支持我們的資本配置優先事項。

Now let me turn to our outlook for 2024. For 2024, we expect consolidated net operating revenues in the range of $19.9 billion to $20.3 billion. Our projected consolidated adjusted EBITDA for '24 is in the range of $3.285 billion to $3.485 billion. For clarity, these revenue and adjusted EBITDA figures for full year '24 reflect the completion of the sale of our coastal South Carolina hospitals on January 31, 2024, and it assumes that the sale of our 4 California hospitals will be completed on March 31, 2024.

現在讓我談談我們對 2024 年的展望。對於 2024 年，我們預計合併淨營業收入將在 199 億至 203 億美元之間。我們預計 24 年綜合調整後 EBITDA 將在 32.85 億美元至 34.85 億美元之間。為了清楚起見，24 年全年的這些收入和調整後EBITDA 數據反映了我們於2024 年1 月31 日完成的南卡羅來納州沿海醫院的出售，並假設我們的4 家加州醫院的出售將於3 月31 日完成， 2024 年。

Now as we discussed previously, there are a number of items that impact the comparison of our '23 results to our '24 outlook, which are outlined on Slide 8 of our investor presentation.

正如我們之前所討論的，有許多因素會影響我們 23 年業績與 24 年前景的比較，這些因素在我們投資者簡報的幻燈片 8 中進行了概述。

Let me summarize the primary drivers as follows: First, we recognized $16 million of grant income in 2023; and second, we recorded income of $34 million associated with cybersecurity insurance proceeds in 2023; third, there are $98 million of headwinds for '24 arising from the termination of COVID-related government funding programs in '23, new regulations related to workers' compensation and personal injury reimbursement in Florida, and changes to health care wages due to the recent minimum wage loss in California; fourth, the closing of our South Carolina hospital sale on January 31, creates a year-over-year EBITDA headwind of $140 million; and finally, our California hospital sale is assumed to create a year-over-year EBITDA headwind of $55 million.

讓我將主要驅動因素總結如下：首先，我們確認 2023 年的贈款收入為 1,600 萬美元；其次，2023 年我們與網路安全保險收益相關的收入為 3,400 萬美元；第三，由於 23 年終止與 COVID 相關的政府資助計劃、佛羅裡達州與工人賠償和人身傷害報銷相關的新規定，以及由於最近的加州最低工資損失；第四，我們的南卡羅來納州醫院出售於 1 月 31 日結束，導致 EBITDA 年減 1.4 億美元；最後，假設我們的加州醫院出售將帶來 5500 萬美元的年比 EBITDA 逆風。

After normalizing for these items, our full year 2024 adjusted EBITDA is expected to grow 7% over '23 at the midpoint of our range.

在這些項目正常化後，我們 2024 年全年調整後的 EBITDA 預計將比 23 年增長 7%，處於我們範圍的中點。

Our '24 outlook assumes continued organic volume growth, strong patient acuity, better than historical contract negotiations and effective cost management, with the specific expectations for additional contract labor savings on a full year basis, partially offset by incremental medical fees. We also assume that we will have contributions from M&A and de novo center openings at USPI given its robust pipeline.

我們的 24 年展望假設銷售持續成長、患者敏銳度高、合約談判優於歷史記錄以及有效的成本管理，並預計全年將節省額外的合約勞動力，部分被增加的醫療費用所抵消。鑑於其強大的管道，我們還假設我們將從 USPI 的併購和從頭中心開設中獲得貢獻。

In addition, for '24, we're also assuming the following: same-hospital admissions growth of 1% to 3%, adjusted admissions growth of 1% to 3%, same facility USPI surgical case growth of 1% to 3% and USPI net revenue per case growth of 2% to 3%.

此外，對於 24 年，我們還假設以下情況：同家醫院入院人數增加 1% 至 3%，調整後入院人數增加 1% 至 3%，同一機構 USPI 手術病例增加 1% 至 3%， USPI每箱淨收入成長2%至3%。

At a segment level, we expect adjusted EBITDA to grow 8.7% at USPI and 4.5% for our Hospital Segment at the respective midpoints of our guidance ranges on a normalized basis. As Saum stated, we believe our guidance range represents attractive growth for Tenet following a very strong 2023.

在分部層面，我們預計 USPI 調整後 EBITDA 將成長 8.7%，醫院分部調整後 EBITDA 將成長 4.5%，分別處於我們標準化指引範圍的中點。正如 Saum 所說，我們相信我們的指導範圍代表了 Tenet 在 2023 年非常強勁之後的有吸引力的增長。

Finally, we would expect first quarter of '24 consolidated adjusted EBITDA to be in the range of $800 million to $850 million, we anticipate that USPI's EBITDA in the first quarter this year will be 20.5% to 22% of our full year 2024 USPI EBITDA guidance at the midpoint.

最後，我們預計 24 年第一季合併調整後 EBITDA 將在 8 億至 8.5 億美元之間，我們預計今年第一季合併調整後 EBITDA 將占我們 2024 年全年 USPI EBITDA 的 20.5% 至 22%中點引導。

Turning to our cash flows for '24. We expect free cash flows in the range of $875 million to $1.125 billion, which includes the payment of $635 million in net taxes related to our announced divestitures. Before these tax payments, this represents $1.635 billion of free cash flow at the midpoint of our '24 outlook, which demonstrates continued strong performance from '23 even after the loss of EBITDA from the divested hospitals in '24.

轉向我們 24 年的現金流。我們預計自由現金流在 8.75 億美元至 11.25 億美元之間，其中包括與我們宣布的資產剝離相關的 6.35 億美元淨稅款。在支付這些稅款之前，這代表我們 24 年展望中點的 16.35 億美元自由現金流，這表明即使在 24 年剝離醫院的 EBITDA 損失之後，23 年的業績仍持續強勁。

We also note the $635 million of taxes paid is comprised of $825 million of taxes associated with the gains on sales, partially offset by $190 million of tax benefits due to a reduction in interest expense limitations.

我們也注意到，所繳納的 6.35 億美元稅款包括 8.25 億美元與銷售收益相關的稅款，部分被利息支出限制減少所帶來的 1.9 億美元稅收優惠所抵銷。

In addition, for 2024, we're also assuming capital expenditures in the range of $775 million to $875 million, distributions to noncontrolling interests in the range of $650 million to $700 million, and our intention to retire the $2.1 billion of senior secured first lien notes due in 2026 in the first quarter of 2024.

此外，我們也假設2024 年的資本支出在7.75 億美元至8.75 億美元之間，向非控制權益的分配在6.5 億美元至7 億美元之間，並且我們打算撤銷21 億美元的高級有擔保第一留置權2026年到期的票據將於2024年第一季到期。

Our cash flow performance has improved substantially over the past several years, and we continue to demonstrate the ability to generate this cash flow while also deleveraging our balance sheet, maintaining investments in our business and executing on key growth plans. We expect this performance to continue in 2024, which will create additional opportunities to delever and grow our business.

在過去幾年中，我們的現金流績效有了顯著改善，並且我們繼續展示產生現金流的能力，同時還可以去槓桿化我們的資產負債表，維持對業務的投資並執行關鍵增長計劃。我們預計這種表現將持續到 2024 年，這將為我們的業務去槓桿化和發展創造更多機會。

And finally, as a reminder, our capital deployment priorities have not changed. First, we plan to allocate $250 million of capital annually to grow USPI. Second, we expect to invest in key hospital growth opportunities, including our focus on higher acuity service offerings. Third, we will evaluate opportunities to retire and/or refinance debt and finally, a balanced approach to share repurchases, depending on market conditions and other investment opportunities.

最後，提醒一下，我們的資本部署優先事項沒有改變。首先，我們計劃每年分配 2.5 億美元的資金來發展 USPI。其次，我們預計將投資於關鍵的醫院成長機會，包括我們專注於提供更高敏銳度的服務。第三，我們將根據市場狀況和其他投資機會評估退休和/或債務再融資的機會，最後評估平衡的股票回購方法。

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 comes from the line of Cal Sternick with JPMorgan Chase & Company.

（操作員說明）我們的第一個問題來自摩根大通公司的 Cal Sternick 線路。

Congrats on a really strong 2023. I want to dig into the 1% to 3% case growth for USPI. It sounds like demand is still strong, and this is more of a comp headwind just given the strong growth in 2023. Is that the right way to think about it? Or is there anything else in terms of mix or demand that's influencing your 2024 outlook? And then if you could also give some color on the level of demand you're anticipating across categories like ortho, cardiac, GI and some of the others, just compared to what you saw in 2023, that would be really helpful.

恭喜 2023 年的強勁表現。我想深入研究 USPI 1% 到 3% 的病例成長。聽起來需求仍然強勁，考慮到 2023 年的強勁成長，這更像是一種競爭逆風。這是正確的思考方式嗎？或者在組合或需求方面還有什麼其他因素會影響您對 2024 年的展望嗎？然後，如果您還可以對您預期的正畸、心臟、胃腸道和其他一些類別的需求水平給出一些顏色，與您在 2023 年看到的情況相比，那將非常有幫助。

No, your interpretation is right. I mean we anticipate continued strong growth in the ambulatory surgery segment. I mean, 2023 was a very strong year, and it was across service lines, as I pointed out, GI, urology, ENT, orthopedics, ophthalmology. I mean we had strength across the board. We had physician additions across the board. Total joint surgeries grew significantly in the fourth quarter, even above what we were running during the course of the year. So we feel very good about that going forward.

不，你的解釋是對的。我的意思是，我們預計門診手術領域將持續強勁成長。我的意思是，2023 年是非常強勁的一年，正如我指出的那樣，它涉及多個服務領域，包括胃腸科、泌尿科、耳鼻喉科、骨科、眼科。我的意思是我們在各方面都有實力。我們全面增加了醫生。第四季關節手術總數顯著成長，甚至高於我們全年的手術量。所以我們對未來的發展感覺非常好。

Yes. Look, I would say that, first of all, the comp in the first quarter is really, really strong based upon the recovery we saw. And we're very analytically driven in the way we look at this. I mean our GI physicians over the course of '23 performed more than 15% more procedures than they did in the prior year as individuals. That's a pretty big leap. And we think it's sustainable. I mean, one of the things that we're doing with some of our more innovative GI physician group partners is focusing on how we hardwire our operating efficiency in the ASCs to allow them to be more productive on a sustainable basis going forward so that, that recovery volume, whatever proportion of that may be becomes their norm. And that's a really, really good lesson learned from '23, about our ability to actually deliver case volumes at that high level of productivity.

是的。聽著，我想說，首先，根據我們看到的復甦，第一季的業績非常非常強勁。我們看待這個問題的方式非常具有分析性。我的意思是，我們的胃腸科醫生在 23 年期間執行的手術比前一年多了 15% 以上。這是一個相當大的飛躍。我們認為這是可持續的。我的意思是，我們正在與一些更具創新性的胃腸道醫師團體合作夥伴一起做的事情之一是，重點關注如何硬連接我們在ASC 中的運營效率，以使他們在可持續的基礎上提高生產力，以便，恢復量，無論其比例是多少，都成為他們的標準。這是從 23 年學到的一個非常非常好的教訓，關於我們以如此高的生產力水平實際交付案件量的能力。

The fact is, if you look back over time, long periods of time, 15, 20 years, when you have notably strong growth years, you often have just based on comps some slightly lower volume rates. But look, we've developed a pattern now of being mindful of what we see in the environment. But if the business outperforms raising our guidance just like we did in 2023, if in fact, it's warranted. Again, I'm very optimistic about 2024, and there's really no other way to interpret that. other than what we just talked about.

事實是，如果你回顧一段時間，很長一段時間，15 年、20 年，當你有特別強勁的增長年份時，你通常會根據比較得出一些略低的銷量率。但是看，我們現在已經形成了一種專注於我們在環境中看到的東西的模式。但如果該業務的表現優於我們上調的指導，就像我們在 2023 年所做的那樣，如果事實上的話，這是有道理的。再說一遍，我對 2024 年非常樂觀，而且確實沒有其他方法可以解釋這一點。除了我們剛才談到的以外。

Our next question comes from the line of A.J. Rice with UBS.

我們的下一個問題來自 A.J.賴斯與瑞銀。

Obviously, the headlines around the last couple of divestitures grabbed some headlines. Maybe I thought I'd ask you about 2 aspects of that. The price tags on the deals, I know these are growth areas once you're selling these hospitals, but seem unusually high by historic standards. Is there any dynamic in the marketplace that you see that nonprofits are bringing to bear. I don't know whether it would be their ability to implement a 340B program or something like that that's causing them to be willing to pay these relatively high valuations.

顯然，最近幾次資產剝離的頭條新聞佔據了一些頭條新聞。也許我想問你兩方面的問題。我知道，一旦你出售這些醫院，交易上的價格標籤就會成為成長領域，但以歷史標準來看，這些價格似乎異常高。您是否看到非營利組織正在為市場帶來任何活力？我不知道他們是否有能力實施 340B 計劃或類似的事情，導致他們願意支付相對較高的估值。

And then second to that is your national strategy of contracting hospitals getting the leverage of both hospitals and the surgery centers, do you think there's any issues with divesting hospitals that would lessen your ability to get the pricing you want on the surgery centers? Or that's not really a question mark.

其次是你們的國家策略，即簽約醫院獲得醫院和手術中心的影響力，您認為剝離醫院是否存在任何問題，會降低您在手術中心獲得所需定價的能力？或者說這其實不是一個問號。

Yes. A.J. Look, on the first point, I would say that -- and I can't put myself in the shoes of not-for-profit health system partners who are looking to acquire assets, but what I would say is that these 2 transactions demonstrate that the work we've done over the last 5 years to generate high-quality, well-performing, solid, quality safety service hospitals with a higher-acuity procedure-based platform can generate a premium because it's a lot of work to get them into that position of not only having a high degree of profitability, but also having a quality service profile that's attractive from a starting standpoint. So they're high-quality assets.

是的。 A.J.聽著，關於第一點，我想說的是——我不能把自己置於尋求收購資產的非營利醫療系統合作夥伴的立場上，但我想說的是，這兩筆交易表明我們在過去5 年所做的工作是建立高品質、表現良好、可靠、優質的安全服務醫院，並擁有基於更高敏銳度的手術平台，可以產生溢價，因為要獲得這些服務需要做大量的工作不僅具有高度的獲利能力，而且還具有從一開始就有吸引力的優質服務概況。所以它們是優質資產。

The other factor, of course, would be that these assets are coming forward in as multiple assets in a market, which, again, are relatively rare. And our point of view is that we recognize that value and we hold out for that type of value in order to ensure that we're doing the right thing from the standpoint of our capital structure and shareholders. Remember, we've said all along, we're very comfortable operating the entirety of this portfolio and doing well with it, and we still are. That doesn't change.

當然，另一個因素是這些資產在市場上作為多種資產出現，這也是相對罕見的。我們的觀點是，我們認識到這種價值，並堅持這種價值，以確保從資本結構和股東的角度來看，我們正在做正確的事情。請記住，我們一直說過，我們對整個投資組合的運作非常滿意，而且做得很好，現在仍然如此。這並沒有改變。

On your second question, all of our divestiture activity that we would entertain would be consistent with our strategy of remaining very high on the list of being a value-based care contributor to the stakeholders, whether government or private pay that engage with our system. And that's definitely the case based upon our lower-cost ambulatory profile. It's also definitely the case based upon the very desirable high-quality acute care assets that we have. So our point of view is that we will remain consistent with our stated strategy on the portfolio, but we also will continue to put effort into making sure that we are delivering solid value for our payer stakeholders, again, both government and private.

關於你的第二個問題，我們將進行的所有剝離活動都將符合我們的策略，即成為利益相關者的基於價值的護理貢獻者，無論是參與我們系統的政府還是私人支付。基於我們低成本的門診概況，情況確實如此。基於我們擁有的非常理想的高品質急診資產，情況也絕對如此。因此，我們的觀點是，我們將與我們既定的投資組合策略保持一致，但我們也將繼續努力確保我們為支付方利害關係人（無論是政府還是私人）提供堅實的價值。

Our next question comes from the line of Brian Tanquilut with Jefferies.

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

Congrats on the quarter. Saum, just to follow up on the divestiture question, right? I mean this seems to be more opportunistic than not in terms of the assets that you've sold. So how are you thinking about maybe longer-term leverage targets or your willingness or interest to look for other opportunities, such as South Carolina and Southern Cal?

恭喜本季。 Saum，只是為了跟進剝離問題，對嗎？我的意思是，就您已出售的資產而言，這似乎更具機會主義色彩。那麼，您如何考慮長期槓桿目標或您尋找其他機會（例如南卡羅來納州和南加州）的意願或興趣？

Yes, they're -- both of these opportunities we're opportunistic, as you say, we were not in the marketplace looking for those, although as I just mentioned to A.J., we have a strategic sense of what we would entertain at what values. And again, we remain opportunistic. But most importantly, we remain committed to the portfolio that we have and running it at a high quality with solid earnings from that standpoint that we can deliver.

是的，這兩個機會我們都是機會主義的，正如你所說，我們並不是在市場上尋找這些機會，儘管正如我剛才向A.J. 提到的，我們對我們將在什麼領域享受什麼有戰略意識。價值觀。再說一遍，我們仍然保持機會主義。但最重要的是，我們仍然致力於我們擁有的投資組合，並以高品質運行它，從我們可以提供的角度來看，我們可以獲得穩定的收益。

So I mean, I'm not sure how to answer the question on a go-forward basis other than to say we have demonstrated thoughtful divestiture activity in a way that remains consistent with our strategy and enhances not just our leverage position, but our belief in our ability to generate free cash flow going forward.

所以我的意思是，我不確定如何在未來的基礎上回答這個問題，除了說我們已經展示了深思熟慮的剝離活動，其方式與我們的戰略保持一致，不僅增強了我們的槓桿地位，而且增強了我們的信念我們未來產生自由現金流的能力。

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

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

Appreciate all the detail and consolidating Conifer, I think, was a good idea. I appreciate that, too. The -- my questions were, one, the bigger question is just that there's been some discussion out there that ahead of the Two-Midnight Rule, a bunch of hospitals might have tightened up how they report observation versus inpatient.

我認為，欣賞所有細節並鞏固 Conifer 是個好主意。我也很欣賞這一點。我的問題是，第一，更大的問題是，在午夜兩點規則之前，已經有一些討論，一些醫院可能會收緊報告觀察與住院患者的方式。

Curious if you've seen any of that internally? How have you prepared? Did you see any benefit this year? What do you think the benefit is next year? And then just a quick numbers question. How many de novo openings this year? Do you expect -- I apologize if I missed that previously.

好奇您是否在內部看過這些內容？你準備得怎麼樣了？今年你看到什麼好處了嗎？您認為明年的好處是什麼？然後是一個簡單的數字問題。今年有多少個從頭開業？你期待嗎——如果我之前錯過了，我深表歉意。

Well, obviously, we're very cognizant of the impact of CMS' commentary on the Two-Midnight Rule, Medicare Advantage is very important to us and being a good partner to our Medicare Advantage health plans and also our medical groups and organized medical groups that participate in Medicare Advantage is something we actually are quite focused on operationally because we are focused on delivering good throughput. We only admit patients through the emergency department when appropriate. We have high standards for that. So we end up being in a position where being focused on MA is important.

顯然，我們非常清楚 CMS 對午夜兩點規則的評論的影響，Medicare Advantage 對我們非常重要，並且是我們 Medicare Advantage 健康計劃以及我們的醫療團體和有組織的醫療團體的良好合作夥伴參與Medicare Advantage 的人實際上是我們在營運上非常關注的事情，因為我們專注於提供良好的吞吐量。我們僅在適當的情況下透過急診收治患者。我們對此有很高的標準。因此，我們最終處於專注於 MA 的位置，這一點很重要。

Now look, we also believe strongly that when people are in the hospital and are sick enough and their condition warrants it based upon the admitting physician's judgment to be inpatients versus an alternative outpatient-based status, that is the appropriate thing to do. And we very much agree with the guidance from CMS that, that should be tightened up. So operationally, we're focused on it. Remember, we also, through Conifer, have the ability to focus on it for us and our clients in terms of ensuring that we have the appropriate documentation in order to defend that position.

現在看，我們還堅信，當人們住院並且病得很嚴重，並且根據入院醫生的判斷，他們的病情證明是住院患者還是門診患者狀態時，這是正確的做法。我們非常同意 CMS 的指導意見，即應該加強這一點。因此，在操作上，我們重點關注它。請記住，透過 Conifer，我們也有能力為我們和我們的客戶專注於這一點，確保我們擁有適當的文件來捍衛這一立場。

So we're going to keep at that. We haven't quantified any potential upside from that, although we have considered it, obviously, in our guidance, but we haven't specifically called out anything from that perspective. The de novo number for 2024, I'd have to -- yes, I'd have to go take a look at an exact number, but it's north of 10, potentially approaching 15. I'm sorry that I don't have an exact number for you.

所以我們會堅持下去。我們還沒有量化任何潛在的好處，儘管我們顯然在我們的指導中考慮了這一點，但我們沒有從這個角度具體指出任何內容。 2024 年的從頭數字，我必須——是的，我必須去看看一個確切的數字，但它在 10 之上，可能接近 15。很抱歉，我沒有給你一個準確的數字。

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

我們的下一個問題來自美國銀行的 Kevin Fischbeck。

I just wanted to dig in a little bit into the view about the Hospital business guidance for 2024. Were you talking about 4.5% normalized performance and 3.6% organic growth there, which seems a little bit low based upon -- it looks like you're looking for a pretty solid volume growth as you get pricing. But based on solid volume growth, I view that labor is going to continue to improve, I'm just trying to figure out if there's any other offsets that you're already kind of backing out the rate pressure and labor changes in there. I would have thought that number would have been higher than the 3% to 4%.

我只是想深入探討一下對 2024 年醫院業務指導的看法。您是在談論 4.5% 的正常化業績和 3.6% 的有機增長嗎？這似乎有點低，因為您看起來像「當您獲得定價時，我們正在尋找相當穩定的銷售成長。但基於穩定的銷售成長，我認為勞動力將繼續改善，我只是想弄清楚是否有任何其他抵消措施可以抵消利率壓力和勞動力變化。我原以為這個數字會高於 3% 至 4%。

Kevin, it's Saum. Let me start. Look, I think a couple of points that I made. First of all, we had an outstanding year in the hospital segment. As you know, every quarter, we exceeded our expectations there.

凱文，我是索姆。讓我開始吧。聽著，我認為我提出了幾點。首先，我們在醫院領域度過了出色的一年。如您所知，每個季度我們都超出了我們的預期。

Look, for us, I mean, we took a lot of the benefit from contract labor reduction in '23. Now don't get me wrong, there's an annualization effect that will improve in the coming year. The volume strength was also very good during the year. And so I think that we believe that we'll continue to see acute care recovery in 2024, like we saw in 2023. And if we're able to open up capacity effectively to service the demand that we want, which again is consistent with our high acuity strategy, I think that's what gets us to the upper end of our guidance, right? It's really the volume potential there.

聽著，對我們來說，我的意思是，我們在 23 年從合約工減少中獲益匪淺。現在不要誤會我的意思，年化效應將在來年改善。這一年的成交量強度也非常好。因此，我認為我們相信，我們將在 2024 年繼續看到急診護理的復甦，就像我們在 2023 年看到的那樣。如果我們能夠有效地開放能力來滿足我們想要的需求，這又與我們的高敏銳度策略，我認為這就是讓我們達到指導上限的原因，對嗎？這確實是那裡的成交量潛力。

And then we're mindful of the fact that there are some things in the operating environment to think about. We did very well, but did have cost increases in '23 in medical fees. We're anticipating some impact of that again, but we think manageable and in the guidance from that perspective. Sun, I don't know if you want to add anything.

然後我們注意到操作環境中有一些事情需要考慮。我們做得很好，但 23 年的醫療費用確實有所增加。我們預計會再次產生一些影響，但我們認為這是可控的，並且從這個角度來看是有指導意義的。孫老師，不知道您是否還需要補充什麼？

Yes. Saum. Just on your last point, I would also add on the medical fees, we did see about 15% total increase in fiscal '23. For '24, we are assuming some moderation in the rate of growth here. So our '24 assumption is in the 8% to 10% range for net fees.

是的。索姆.關於你的最後一點，我還要補充醫療費用，我們確實看到 23 財年的總增幅約為 15%。對於 24 年，我們假設成長率有所放緩。因此，我們對 24 年淨費用的假設是在 8% 到 10% 的範圍內。

Our next question comes from the line of Whit Mayo with Leerink Partners.

我們的下一個問題來自 Whit Mayo 和 Leerink Partners 的電話。

I just was curious on how you feel about the target for 575 to 600 centers for 2025, you need about 15 new centers a year over the next 2 years to get there, about a 20% increase. So I just wanted to take your temperature on how you're feeling about that target.

我只是很好奇您對 2025 年 575 至 600 個中心的目標有何看法，未來 2 年每年需要大約 15 個新中心才能實現這一目標，增幅約為 20%。所以我只是想了解你對這個目標的感受。

Whit. I mean, first of all, the pipeline is very robust at this stage and healthy, inclusive of both single centers and platforms that have multiple centers within it, a good mix of acuity across different services, meaning orthopedics and other things in addition.

惠特。我的意思是，首先，現階段的管道非常強大且健康，包括單一中心和內部有多個中心的平台，不同服務之間的敏銳度的良好組合，這意味著骨科和其他服務。

So look, I mean the 575 to 600 is a range that we put out there as a target by that standpoint. One of the things that we're going to be disciplined about is we're going to do good deals, high-quality assets, attractive multiples, not overpaying and ultimately, being able to deliver earnings growth in those facilities and organic growth in those facilities in a way that we got it. So we're not going to chase a number, but our pipeline at this point makes me feel good about the fact that if things come together the right way, we could reach that target by the end of '25.

所以看，我的意思是 575 到 600 是我們從這個角度出發作為目標的範圍。我們要遵守的一件事是，我們將進行良好的交易、高品質的資產、有吸引力的市盈率，而不是支付過高的價格，並最終能夠實現這些設施的盈利增長和這些設施的有機增長。設施以我們得到的方式。所以我們不會追逐一個數字，但我們目前的管道讓我感覺良好，因為如果事情以正確的方式進行，我們可以在 25 年底實現該目標。

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

我們的下一個問題來自加拿大皇家銀行資本市場的 Ben Hendrix。

Your ambulatory net revenue per surgical case outlook, 2% to 3%, seems consistent with what we think of longer-term steady-state growth, just wondering if there's potential for upside there from continued acuity migration within the same-store base? Or is acuity something you're pursuing through just more through a function of new development?

每個手術病例的流動淨收入前景為 2% 至 3%，似乎與我們對長期穩態增長的看法一致，只是想知道同店基礎內持續的敏銳度遷移是否有上漲的潛力？或者你所追求的敏銳度只是更多地透過新發展的功能而實現的？

A couple of thoughts, yes. I mean 2% to 3% is kind of our long-term estimate. We have, obviously, as I indicated, somewhat purposefully a very high degree of visibility into our managed care pricing and obviously, the Medicare pricing for 2024. The acuity and mix potentially represents some upside there.

有幾個想法，是的。我的意思是 2% 到 3% 是我們的長期估計。顯然，正如我所指出的，我們有目的地對我們的管理式醫療定價以及 2024 年的醫療保險定價有非常高的了解。敏銳度和組合可能代表著一些上行空間。

If you think about 2023 where we saw a lot of recovery in GI and ENT cases, even a relative mix shift could impact the acuity in 2024. And that's got pluses and minuses associated with it, right, if the mix shifts from that perspective. But strategically, our plan is to continue to increase our high acuity services. Look, we're also mindful of the fact, and we don't spend a lot of time talking about it anymore, but we are still doing some work to move slightly higher volume, very, very low acuity work out of our ASCs into other settings in order to make room for higher acuity, we're doing it in a more measured way than we perhaps did in 2022, but we're still doing it. And so that also presents upside if we're successful in refreshing those partnerships. But we think that will serve us well for the longer term.

如果你想想2023 年，我們看到胃腸道和耳鼻喉科病例有很大的恢復，即使是相對的組合變化也可能會影響2024 年的敏銳度。如果從這個角度來看組合發生變化，那麼這就會有優點和缺點，對吧。但從策略上講，我們的計劃是繼續增加我們的高敏銳度服務。聽著，我們也注意到了這一事實，我們不再花很多時間談論它，但我們仍在做一些工作，將稍高的容量、非常非常低的敏銳度工作從我們的 ASC 轉移到為了給更高的敏銳度騰出空間，我們正在以比2022 年更加謹慎的方式來做這件事，但我們仍在這樣做。因此，如果我們成功地更新這些合作關係，這也會帶來好處。但我們認為，從長遠來看，這對我們有好處。

Our next question comes from the line of Josh Raskin with Nephron Research LLC.

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

I want to stick with USPI. Can you speak to the revenue per case growth in the ASC segment that we saw in 4Q? It seems like the same-store revenues were more case-driven earlier in the year. So I'm just curious if 4Q was higher acuity cases or mix related as you were just talking about.

我想堅持使用 USPI。您能談談我們在第四季度看到的 ASC 細分市場的每箱收入成長嗎？今年早些時候，同店收入似乎更多是由案例驅動的。所以我只是好奇 4Q 是否是更高敏銳度的情況或與您剛才談論的混合相關。

And then I'm just curious, relatedly, are there any differences in the trends on the same-store relative to those that have been acquired or newly consolidated versus those that you've had a little bit longer? I'm thinking about some of the SCD assets that may not have been as mature and thinking about as those move into the same-store revenue number, is that going to keep that sort of total same-store revenue number growth higher?

然後我只是很好奇，與此相關的是，同家商店的趨勢與那些已經被收購或新整合的商店相比，與那些你已經擁有更長一段時間的商店相比，是否有任何差異？我正在考慮一些可能還沒有那麼成熟的 SCD 資產，並考慮將這些資產納入同店收入數字，這是否會使同店總收入數字增長更高？

Let me start with your second question and then pass over to Sun for the first one. I don't think we see a major difference across the board. I mean look, there's a lot of centers, obviously, some are more mature than others. And it's a portfolio, right? So some are -- of course, there's a bell curve and some are growing faster than others, of course, from that standpoint.

讓我從第二個問題開始，然後將第一個問題轉交給Sun。我認為我們沒有看到全面的重大差異。我的意思是，你看，有很多中心，顯然，有些中心比其他中心更成熟。這是一個投資組合，對吧？當然，從這個角度來看，有些企業存在鐘形曲線，有些企業的成長速度比其他企業快。

But I wouldn't necessarily say or break it down by particular segments. I think the most important segmentation in '23 was that you could clearly see the GI-only centers grew faster than others on average. But the growth was pretty strong in segments beyond GI. But it was definitely faster in the GI-only centers. That's probably the most obvious trend that I've noticed. Your first question.

但我不一定會說或將其分解為特定的部分。我認為 23 年最重要的細分是，您可以清楚地看到僅 GI 中心的平均成長速度比其他中心快。但地理標誌以外的細分市場成長相當強勁。但在只有 GI 的中心，速度肯定更快。這可能是我注意到的最明顯的趨勢。你的第一個問題。

Josh, this is Sun. In the ambulatory space in Q4 of '23, I think you're right, we did see elevated net revenue per case. It was about 5.4% higher than the previous for Q4 in '22. But if you take a step back and look to the rest of '23, those rates are a little bit lower, right? So that for fiscal '23 overall, our NRPC was about 3.4% higher than '22.

喬什，這是孫。在 23 年第四季的門診領域，我認為你是對的，我們確實看到每個病例的淨收入增加。比 2022 年第四季成長約 5.4%。但如果你退一步看看 23 年剩下的時間，這些比率會低一點，對吧？因此，就 23 財年整體而言，我們的 NRPC 比 22 財年高出約 3.4%。

So I think it's partly what Saum mentioned, mix of different procedures, gastro, ortho, some of the other ones. And I don't know that I would read too much more into that. And then as we said, our guidance for fiscal '24 assumes a 2% to 3% range, which compares reasonably well to the 3.4% that I just mentioned for all of fiscal '23.

所以我認為這部分是索姆提到的，不同手術的混合，胃腸道、矯正和其他一些手術。我不知道我會讀太多這方面的內容。正如我們所說，我們對 24 財年的指導假設為 2% 至 3% 的範圍，這與我剛剛提到的 23 財年整個財年的 3.4% 相比相當不錯。

Our next question comes from the line of Sarah James from Cantor Fitzgerald.

我們的下一個問題來自康托·菲茨杰拉德的莎拉·詹姆斯。

As we move past the pandemic, most of the providers have been talking about kind of repricing on the commercial side in the mid-single-digit range for hospitals. Can you give us an idea, given the timing of your repricing, how much of that -- how much of your book was already at this higher rate in 4Q, how much do you expect to be in the rate for '24? And is there any aspect of that, that includes covering some of the unreimbursed physician fees for the third-party anesthesiologists. So is that being worked into the rates at this point?

隨著疫情的過去，大多數提供者一直在討論在商業方面對醫院進行中個位數的重新定價。您能否給我們一個想法，考慮到您重新定價的時間，其中有多少 - 您的書有多少內容在第四季度已經達到了較高的費率，您預計 24 年的費率是多少？其中是否有任何方面，包括支付第三方麻醉師的一些未報銷的醫生費用。那麼目前這一點是否已納入費率？

It's Saum. Again, in a little bit of reverse order. I mean, obviously, we take into consideration all aspects of inflationary pressures whether that be contract labor, physician, physician partnerships, supply -- I mean all of it, right? I mean into the way in which we approach our negotiations with our health plans.

是索姆。再次，以稍微相反的順序。我的意思是，顯然，我們考慮了通貨膨脹壓力的各個方面，無論是合約工、醫生、醫生合作夥伴關係、供應——我的意思是所有這些，對吧？我的意思是我們與健康計劃進行談判的方式。

And I mean, as we've indicated in the past, it's not like somebody's come forward in the last few years, government or private pay and just offered up CPI, right? But the thing is we have annual escalators in all of our contracts, we're mindful of the fact that to deliver value, obviously, we need to have annual escalators given inflation, but it is also partially our responsibility to continue to find efficiencies in our business in order to remain valued partners to our stakeholders, again, both government and private pay. So that's how we think about it. And that's how we've been able to expand our margins over this period of time.

我的意思是，正如我們過去所指出的那樣，這不像過去幾年有人挺身而出，政府或私人支付費用，只是提供消費者物價指數，對嗎？但問題是，我們所有的合約中都有年度自動扶梯，我們注意到這樣一個事實，為了創造價值，顯然，考慮到通貨膨脹，我們需要每年自動扶梯，但繼續尋找效率也是我們的部分責任。我們的業務，以便繼續成為我們的利害關係人的重要合作夥伴，同樣，政府和私人都付費。這就是我們的想法。這就是我們在這段時間內擴大利潤的方式。

Look, my view is we're generally pretty well contracted for '24. And the bit of tailwind that we see from the recent higher-than-average contract negotiation should be and is part of our guidance in '24. And my guess is it will flow a bit into '25 as well, right? And then we'll see when the next round of negotiations come up how that goes.

聽著，我的觀點是我們 24 年的合約總體上相當不錯。我們從最近高於平均水平的合約談判中看到的一點順風應該是並且確實是我們 24 年指導的一部分。我的猜測是它也會流入 25 年，對吧？然後我們會看看下一輪談判何時進行。

It's really important to understand that part of our strategy in our net revenue per case improvement over time also relies on our ability to continue our acuity of case mix in our hospitals so that together, we're giving ourselves an opportunity to generate that net revenue per case improvement over time. And I think the fourth quarter represented a lot of acuity that we saw in the quarter, which is why the number was so attractive. Sun?

非常重要的是要了解，隨著時間的推移，我們每個病例淨收入改善的策略的一部分也依賴我們繼續保持醫院病例組合敏銳度的能力，這樣我們就可以共同給自己一個創造淨收入的機會隨著時間的推移，每個案例都會得到改善。我認為第四季度代表了我們在本季度看到的許多敏銳度，這就是為什麼這個數字如此有吸引力。太陽？

Saum, I would just -- to confirm kind of what you said. We said historically, we're seeing commercial rate increases in the 3% to 5% range. And going into 2024, we're about 90% contracted. I wouldn't try to segment that too much deeper than that, only to say that those rates are kind of what's embedded into our '24 guidance that we provided.

Saum，我只是想確認你所說的話。我們說過，從歷史上看，我們看到商業利率上漲 3% 到 5% 的範圍。到 2024 年，我們的 90% 左右都會萎縮。我不會嘗試對此進行更深入的細分，只是說這些利率已嵌入到我們提供的 24 年指引中。

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

我們的下一個問題來自德意志銀行的 Pito Chickering。

On the hospital labor side, what are you guys modeling for full-time wage inflation for '24? And how much more savings can we get from contract labor? And because you're including Conifer in that segment now, can you tell us what revenue per adjusted admission is guided to be for this year? And is it safe to think about Conifer EBITDA growing faster than Hospital EBITDA for 2024?

在醫院勞動力方面，你們對 24 世紀全職薪資通膨有何模型？我們還能從合約工中節省多少成本？因為您現在將 Conifer 納入該細分市場，您能否告訴我們今年調整後的每次入場收入指導為多少？認為 2024 年針葉樹 EBITDA 成長速度快於醫院 EBITDA 是否安全？

Yes. Pito, this is Sun. Let me try to take some of those. From a base wage standpoint, obviously, we've been managing base wages efficiently overall, as evidenced by our SWB metrics. I would say '23 was still elevated compared to our historical rates, that's more in the 2% to 3% range. We are assuming more normalized rates in fiscal '24 guidance but probably not fully back to those historical rates yet. I would just add, we're continuing to make investments into our workforce in the right areas on our base wages.

是的。皮托，這是太陽。讓我嘗試選取其中的一些。從基本工資的角度來看，顯然，我們總體上一直在有效地管理基本工資，我們的主觀幸福感指標證明了這一點。我想說，與我們的歷史利率相比，'23 仍然較高，在 2% 到 3% 的範圍內。我們假設 24 財年指引中的利率更加正常化，但可能尚未完全恢復到歷史利率。我想補充一點，我們將繼續在基本工資的基礎上對適當領域的勞動力進行投資。

And then on contract labor, to your point, I think Saum mentioned earlier, we do still expect some savings from contract labor going into fiscal '24 guidance. That would primarily be in the first half of '24, because if you look at our Q3 and Q4 rates of '23, they were about 3% and 2.8%. So I think the room for improvement in the second half of the year for '24 is much lower.

然後在合約工方面，就您的觀點而言，我認為 Saum 之前提到過，我們仍然預計合約工將帶來一些節省，進入 24 財年指導。這主要是在 24 年上半年，因為如果你看看我們 23 年第三季和第四季的利率，它們約為 3% 和 2.8%。所以我認為'24下半年的改進空間要小得多。

And then I'm sorry, your question on Conifer. Now that we've changed our reporting segment methodology, I don't know that we will provide that level of detail.

然後我很抱歉，你關於針葉樹的問題。既然我們已經改變了報告分部方法，我不知道我們是否會提供這種程度的詳細資訊。

Our next question comes from the line of Jason Cassorla with Citi.

我們的下一個問題來自花旗銀行的傑森‧卡索拉 (Jason Cassorla)。

Great. Congrats on the quarter. Maybe a question on cash flow. It looks like you'll still generate enough free cash flow less NCI cash distribution to self-fund that $250 million investment target in the ASCs for '24, even with the tax payment from the divestitures. But I guess, moving beyond this year, Tenet should be in a position to generate well north of $1 billion of free cash flow less cash NCI and you haven't meaningfully reduced your leverage profile.

偉大的。恭喜本季。也許是關於現金流的問題。看起來您仍然會產生足夠的自由現金流（減去 NCI 現金分配），以自籌資金，實現 24 年 ASC 2.5 億美元的投資目標，即使是剝離資產所繳納的稅款。但我想，今年過後，Tenet 應該能夠產生 10 億美元以上的自由現金流減去 NCI 現金，而且您還沒有有意義地降低槓桿率。

So I guess, as you think about the capital deployment priorities, right, do you think you'll be in a position to increase that $250 million ASC target as it does from the divestitures -- are those done? Or how would you frame that?

所以我想，當您考慮資本部署優先事項時，您認為您是否能夠像透過資產剝離那樣增加 2.5 億美元的 ASC 目標——這些都完成了嗎？或者你會如何建構它？

Yes. No, listen, I think the -- first of all, the capital allocation priorities in terms of the 4 categories that we've talked about, obviously, USPI. Again, I can't emphasize enough being importantly supportive of our acute care hospital portfolio to maintain them. Strong and very desirable assets by all stakeholders is really critical to our overall strategy. The deleveraging that we've talked about and then obviously, the share buyback program that we have authorized all remain absolutely important priorities to us, as we look forward.

是的。不，聽著，我認為——首先，我們已經討論過的 4 個類別的資本配置優先級，顯然是 USPI。再次強調，我們必須大力支持我們的急診醫院組合以維持它們。所有利害關係人擁有的強大且非常理想的資產對於我們的整體策略至關重要。展望未來，我們所討論的去槓桿化以及我們已授權的股票回購計劃仍然是我們絕對重要的優先事項。

Now you point out a really -- it's a really important point, which is a little bit of my commentary at the end of my prepared comments about, we're entering a new era for us which is important for us to collectively think about. And if you think about on this call and what I've alluded to, it has raised the question about where are we thinking about leverage targets, which we have not given specifically in the past. What are our capital deployment priority is going to look like and how will they be different? There are some people that would ask and we certainly would consider? Are there enhancements in our capital allocation into our acute care portfolio in our more high-return markets that we still have with us that makes sense.

現在你指出了一個非常重要的觀點，這是我在準備好的評論末尾的一點評論，我們正在進入一個新時代，這對我們集體思考很重要。如果你考慮一下這次電話會議以及我所提到的內容，就會提出一個問題：我們在哪裡考慮槓桿目標，而我們過去沒有具體給出這一目標。我們的資本部署優先順序會是什麼樣子？它們有何不同？有人會問我們一定會考慮嗎？在我們仍然擁有的更高回報市場中，我們對急診護理投資組合的資本配置是否有所增強？

And then obviously, the USPI question of deploying additional capital into that segment. And I think we'll have more to say about that as the year goes on, frankly. But those things are all on our mind. Look, specifically on USPI, we talk about, historically $200 million to $250 million, now closer to $250 million in capital allocation every year. But the fact is, if you go back over the last 5 years and just look at what we've spent and average it out over those 5 years, it's been quite a bit higher than $200 million to $250 million. We will continue to seek opportunities to add high-quality ASCs to our platform and obviously are comfortable going above the $200 million to $250 million if those opportunities exist.

顯然，USPI 的問題是向該領域部署額外資本。坦白說，我認為隨著時間的推移，我們將對此有更多的討論。但這些事情都在我們的腦海裡。看，特別是在 USPI 上，我們談論歷史上每年 2 億至 2.5 億美元的資本配置，現在接近 2.5 億美元。但事實是，如果你回顧過去 5 年，看看我們在這 5 年中花費的金額並將其平均，你會發現它比 2 億至 2.5 億美元要高得多。我們將繼續尋找機會，將高品質的 ASC 添加到我們的平台上，如果有這些機會，顯然我們願意將金額超過 2 億至 2.5 億美元。

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

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

I was hoping you could talk about your expectations for payer mix in 2024 and how that's been factored into your guidance. It obviously looks like there's significant growth coming on the exchange. I'm wondering if that's something you explicitly considered either from a volume growth perspective more inside of your payer mix guidance and kind of how you think about better payer mix could materialize in your guidance range?

我希望您能談談您對 2024 年付款人組合的期望，以及如何將其納入您的指導中。顯然，該交易所將出現顯著成長。我想知道您是否從付款人組合指導中的數量增長角度明確考慮了這一點，以及您如何看待更好的付款人組合可以在您的指導範圍內實現？

Yes, for '24, first of all, in '23, our payer mix remains quite strong as we said previously, with managed care, steady around 70%, and that's what we're sort of expecting in our '24 guidance to stay pretty steady. Your question on the exchange volume. Yes, we are tracking that as well. And could potentially be a tailwind or an opportunity in '24, but we're not assuming anything material from that in our '24 guidance.

是的，對於 24 年，首先，在 23 年，我們的付款人組合仍然相當強勁，正如我們之前所說，管理式醫療穩定在 70% 左右，這就是我們在 24 年指導中所期望的相當穩定。你關於交易量的問題。是的，我們也在追蹤這一點。這可能是 24 年的順風車或機遇，但我們不會在 24 年的指導中假設任何實質內容。

I mean the other thing I would say, in particular, with the exchange growth is that I just would remind the group that we feel pretty good about how well we're contracted in the exchange environment in the states that we operate in, both applicable by the way, to the acute care portfolio, of course, but also applicable to our USPI platform. So just as a note on that.

我的意思是，我要特別說的另一件事是，隨著交易所的成長，我只是想提醒大家，我們對我們在營運所在州的交易所環境中的簽約情況感到非常滿意，這兩個州都適用順便說一句，對於急診護理產品組合，當然也適用於我們的 USPI 平台。所以只是作為一個註解。

Our next question comes from the line of Jamie Perse with Goldman Sachs.

我們的下一個問題來自傑米·珀斯 (Jamie Perse) 與高盛的對話。

I wanted to get your assessment just of the current ASC landscape in terms of competitive activity and new competition in states as well on the funnel, just new procedure categories that are moving in, moving off the inpatient-only list and eventually out to ASCs. Just any perspectives on what you're seeing in the market and sustainability of ASC over the medium term? And then just any comment on if there is a surgical day impact in the fourth quarter?

我想了解您對當前 ASC 格局的評估，包括各州的競爭活動和新競爭以及漏斗中的新程序類別，這些新程序類別正在進入，從僅限住院患者的列表中移出，並最終進入 ASC。您對 ASC 的市場狀況和中期永續性有何看法？然後對第四季度手術日是否有影響有什麼評論嗎？

Okay. I'll leave the surgical day question till the end because I honestly don't know. Look, on your first set of questions, a few things, okay? So one is that we have been -- obviously, we spent a lot of time talking about orthopedics, generally speaking. And obviously, the more traditional things like GI and ENT and things of that nature, ophthalmology.

好的。我會把手術日的問題留到最後，因為老實說我不知道。聽著，關於你的第一組問題，有一些事情，好嗎？因此，一是我們一直——顯然，一般來說，我們花了很多時間談論骨科。顯然，更傳統的東西，如胃腸道和耳鼻喉科以及類似性質的東西，眼科。

But the fact is we have been focused on diversification of our platform for a long time. I mean, take as an example, shoulder surgeries. We have had for over a year now, an innovative program that has helped us grow and develop all the protocols for our ASCs where we do orthopedics to add shoulder surgery to that. Now the numbers are not as big as hips and knees, for example, but we're well prepared to do that. And part of our physician recruitment strategy has been to focus on physicians with interest in shoulder surgeries in the ASC setting, just as an example.

但事實是，我們長期以來一直專注於我們平台的多元化。我的意思是，以肩部手術為例。我們已經開展了一年多的創新計劃，該計劃幫助我們發展和開發了 ASC 的所有協議，我們在 ASC 中進行骨科手術，並在其中添加肩部手術。例如，現在的數字不像臀部和膝蓋那麼大，但我們已經做好了充分的準備。舉個例子，我們的醫生招募策略的一部分是重點關注對 ASC 環境中的肩部手術感興趣的醫生。

I think you guys are well aware of our urology strategy where we think there's a very nice opportunity especially with high-quality groups to move further into the ambulatory surgery setting. We had been growing and expanding some of our bariatrics capability there, which, again, is, in the ASC setting, has been reasonably stable despite the GLP hoopla over the last year. And so our -- and then obviously, growing and expanding some of what one might consider vascular or cardiovascular, but in a measured way, as we look forward from that standpoint.

我認為你們很清楚我們的泌尿外科策略，我們認為這是一個非常好的機會，特別是對於高品質的團隊來說，可以進一步進入門診手術環境。我們在那裡一直在發展和擴大我們的一些減肥治療能力，儘管去年有 GLP 喧囂，但在 ASC 環境中，我們的減肥能力仍然相當穩定。因此，我們的——然後顯然，我們會以一種有節制的方式增長和擴大一些人們可能認為是血管或心血管的東西，正如我們從這個角度展望的那樣。

So I feel pretty good about the fact that our business development and strategic teams are thinking steps ahead from a clinical standpoint, what we want to do. The competitive landscape in the ASC segment is active and intense. And I think that will certainly continue. Look, we think we have a lot of advantages based upon our scale, our physician relationships, our ability to deliver synergies and also just the consistent demonstrated operating excellence over a long period of time. And now we add to that what we think is a best-in-class revenue cycle capability that we've built inside of USPI separate from Conifer, inside the USPI that is starting to do work even for non-USPI centers, which is an exciting development.

因此，我對我們的業務開發和策略團隊正在從臨床角度思考我們想要做什麼這一事實感到非常滿意。 ASC領域的競爭格局活躍且激烈。我認為這種情況肯定會持續下去。看，我們認為我們有很多優勢，基於我們的規模、我們的醫生關係、我們提供協同效應的能力，以及長期持續表現出的卓越營運能力。現在我們添加了我們認為是一流的收入週期功能，我們在 USPI 內部獨立於 Conifer 構建了這種能力，在 USPI 內部甚至開始為非 USPI 中心發揮作用，這是一個令人興奮的發展。

So we're doing a lot to innovate in that business to continue to maintain our leadership position. So I feel very good about where we are competitively there.

因此，我們在該業務上做了很多創新，以繼續保持我們的領導地位。所以我對我們的競爭力感到非常滿意。

And Jamie, just to -- on your final question, yes, there was no impact from a surgical day basis on our growth in Q4. It was 3.9% overall case growth.

傑米，關於你的最後一個問題，是的，手術日對我們第四季的成長沒有影響。整體病例成長率為 3.9%。

And we have reached the end of the question-and-answer session, and this also concludes today's conference. You may disconnect your lines at this time. Thank you for your participation.

問答環節已經結束，今天的會議也到此結束。此時您可以斷開線路。感謝您的參與。