Tenet Healthcare Corp (THC) 2024 Q3 法說會逐字稿

Good morning, and welcome to Tenet Healthcare's third-quarter 2024, earnings conference call. (Operator Instructions)

早安，歡迎參加 Tenet Healthcare 2024 年第三季財報電話會議。（操作員指令）

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

現在我將電話轉給主持人、投資人關係副總裁威爾·麥克道爾先生。麥克道威爾先生，現在可以開始了。

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 third-quarter 2024 results as well as a discussion of our financial outlook.

大家早安，感謝大家參加今天的電話會議。我是投資者關係副總裁威爾麥克道爾 (Will McDowell)。我們很高興您能加入我們討論 Tenet 2024 年第三季的業績以及我們的財務前景。

Tenet senior management participating in today's call will be Dr. Saum Sutaria, 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 高階主管包括董事長兼執行長 Saum Sutaria 博士；以及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.

我們今天早上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。請收聽本次電話會議的聽眾注意，我們今天討論中所做的某些陳述是前瞻性的，代表了管理層根據當前可用的信息所做出的期望。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。投資者應注意今天的簡報中包含的警告聲明幻燈片以及我們最近的 10-K 表格和向美國證券交易委員會提交的其他文件中討論的風險因素。

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

說完這些，我會把電話轉給索姆。

Thanks, Will, and good morning, everybody.

謝謝，威爾，大家早安。

Before we discuss our third quarter results, I'd like to take a moment to acknowledge and pay respect to those impacted by the hurricanes in our company, in our peers in those markets, and in our partners and suppliers who operate in those regions. The devastation is significant, but the energy to recover and rebuild shows the best of the American Spirit rallying together in a crisis.

在我們討論第三季的業績之前，我想花點時間向我們公司中受到颶風影響的人們、這些市場的同行以及在這些地區運營的合作夥伴和供應商表示感謝和敬意。破壞雖然嚴重，但恢復和重建的能量體現了危機中團結一致的美國精神。

Moving on to our results. Once again, our performance in the third quarter exceeded our expectations and represents a continuation of consistently strong operating results driven by volume growth and disciplined operations. In the third quarter, we reported net operating revenues of $5.1 billion. Consolidated adjusted EBITDA was $978 million, representing growth of 15% over third quarter 2023, and an adjusted EBITDA margin of 19.1%. USPI's results were once again strong with $439 million in adjusted EBITDA, which represents 19% growth over third quarter '23.

繼續討論我們的結果。我們第三季的業績再次超出了我們的預期，並且在銷售成長和嚴謹營運的推動下，繼續保持強勁的經營業績。第三季度，我們報告的淨營業收入為 51 億美元。綜合調整後 EBITDA 為 9.78 億美元，較 2023 年第三季成長 15%，調整後 EBITDA 利潤率為 19.1%。USPI 的業績再次強勁，調整後 EBITDA 為 4.39 億美元，較 23 年第三季成長 19%。

Same-facility revenues grew 8.7% and adjusted EBITDA margins remain robust. Orthopedic volumes are strong and total joint replacements in the ASCs were up 19% over prior year, coupled with the ongoing growth in urology and GI procedures. We did open six new de novos in the quarter, including a new partnership with Synergy Orthopedics establishing the largest dedicated musculoskeletal outpatient surgery center in San Diego, California. De novo development activity remains an important part of USPI's growth story and we have nearly 20 centers currently in syndication stages or under construction.

同店營收成長 8.7%，調整後 EBITDA 利潤率維持強勁。骨科手術量強勁，美國骨科中心的關節置換總量比前一年增加了 19%，同時泌尿科和胃腸道手術也持續成長。我們在本季確實開設了六家新診所，包括與 Synergy Orthopedics 建立新的合作夥伴關係，在加州聖地牙哥建立最大的專門肌肉骨骼門診手術中心。從頭開發活動仍然是 USPI 成長故事的重要組成部分，我們目前有近 20 個中心處於聯合階段或正在建設中。

Turning to our hospital segment. Adjusted EBITDA was $539 million in the third quarter representing 11% growth over the third quarter of 2023 and importantly, strong sequential growth. The strong utilization environment remains with same-store hospital admissions up 5.2% as we continue to open up capacity in a cost-efficient way.

談到我們的醫院部門。第三季調整後的 EBITDA 為 5.39 億美元，較 2023 年第三季成長 11%，重要的是，實現了強勁的連續成長。由於我們繼續以具成本效益的方式開放醫院容量，強勁的利用率環境依然存在，同店住院人數增加了 5.2%。

Third quarter 2024 revenue per adjusted admission was up 3.3% over prior year, reflecting continued strength, acuity and mix. We've proven our ability to succeed in tough operating environments, leading the way in 2022 and 2023 in cost management in the aftermath of COVID and now in 2024 with robust demand where our efficient operating chassis has allowed us to deliver stronger results than expected throughout the year.

2024 年第三季調整後每張門票收入較上年增長 3.3%，反映出持續的實力、敏銳度和組合。我們已經證明了我們有能力在艱難的營運環境中取得成功，在2022 年和2023 年COVID 疫情後的成本管理方面處於領先地位，現在在2024 年需求強勁的情況下，我們高效的營運框架使我們能夠在整個過程中提供比預期更強勁的業績年。

As such, we are continuing to make significant investments in expanding our network to support growth in our markets over the coming years. In July, we opened our newest hospital in Westover Hills, a rapidly growing area near San Antonio. The hospital is focused on procedural services with state-of-the-art operating rooms in cath labs, a large emergency department and an entire floor devoted to women's services. Additionally, construction of our next hospital in Port St. Lucie, Florida continues with an opening planned for 2025.

因此，我們將繼續進行大量投資，擴大我們的網絡，以支持未來幾年市場的成長。7月份，我們在聖安東尼奧附近一個快速發展的地區韋斯托弗山開設了最新的醫院。該醫院專注於程序服務，擁有心臟導管室最先進的手術室、大型急診室以及專門為女性服務的整整一層樓。此外，我們位於佛羅裡達州聖露西港的下一家醫院的建設仍在繼續，並計劃於 2025 年開業。

Turning to our full year 2024 guidance. We are once again raising our full year 2024 guidance to a range of $3.9 billion to $4 billion based on the fundamental organic outperformance in both of our business units. This represents an increase of $50 million at the midpoint of the range over our prior guidance increased and announced at the second quarter call. We've now raised our adjusted EBITDA guidance by nearly $600 million from our initial expectations this year. Clearly, we are pleased with our strong performance throughout the year.

談到我們的 2024 年全年指引。基於我們兩個業務部門的基本有機表現優異，我們再次將 2024 年全年業績預期上調至 39 億美元至 40 億美元之間。這比我們在第二季電話會議上宣布的上調後的預期中位數增加了 5,000 萬美元。我們已將今年調整後的 EBITDA 指引較最初的預期上調了近 6 億美元。顯然，我們對全年的強勁表現感到滿意。

Before I turn the call over to Sun, I'd like to spend a little bit of time discussing our portfolio transformation. We completed the sale of our Alabama hospitals on September 30. All of the sales that we have executed on have been at high multiples to reflect the operational improvements that we have made to each of these facilities over the last several years.

在我將電話轉給 Sun 之前，我想花一點時間討論我們的投資組合轉型。我們於9月30日完成了阿拉巴馬州醫院的出售。我們執行的所有銷售都達到了高倍數，反映了我們在過去幾年中對每個設施所做的營運改善。

More importantly, as a result of these sales, our current hospital portfolio has an enhanced return profile more attractive geographies for us and our business model, higher expected returns on invested capital that should result.

更重要的是，由於這些銷售，我們目前的醫院組合具有增強的回報狀況，對我們和我們的商業模式更具吸引力的地理位置，以及更高的預期投資資本回報率。

Conifer has retained and in many cases, expanded its relationship with the acquirers of the hospitals demonstrating the value we deliver to providers and revenue cycle management. While our hospitals are well positioned to benefit from a favorable operating environment, we've built a leadership team and a culture of operating discipline to be able to execute and deliver results during more challenging times as well.

Conifer 在許多情況下保留了與醫院收購方的合作關係，並擴大了這種關係，展示了我們為供應商和收入週期管理提供的價值。雖然我們的醫院已經準備好從有利的營運環境中獲益，但我們已經建立了一個領導團隊並建立了一種營運紀律文化，以便能夠在更具挑戰性的時期執行並交付成果。

The actions we have taken have enabled us to significantly improve our leverage ratio and we are committed to a deleveraged balance sheet going forward. After accounting for the tax payments that are still due on asset sales, our leverage ratio on an EBITDA minus NCI basis is around 3. We are very pleased with the deleveraging accomplished to date.

我們所採取的行動使我們顯著改善了槓桿率，並致力於在未來實現去槓桿的資產負債表。在考慮資產銷售應支付的稅款後，我們以 EBITDA 減去 NCI 為基礎的槓桿率約為 3。我們對迄今為止完成的去槓桿工作感到非常滿意。

Looking forward, we are well positioned to create value for shareholders through stronger free cash flow generation. Our transformed portfolio provides us with a high degree of capital and financial flexibility. We will continue to deploy capital to enhance growth in our industry-leading ambulatory surgical business through M&A and de novo development, increased capital spending to fuel organic growth and return excess capital to shareholders via share repurchase given that we believe our equity continues to trade at attractive multiples relative to the market.

展望未來，我們有能力透過更強的自由現金流為股東創造價值。我們轉型後的投資組合為我們提供了高度的資本和財務靈活性。我們將繼續部署資本，透過併購和新藥開發來促進我們行業領先的門診手術業務的成長，增加資本支出以促進有機成長，並透過股票回購將多餘的資本返還給股東，因為我們相信我們的股票繼續交易相對於市場而言具有吸引力的倍數。

The combination of an established management team of focused strategy and consistent operations and disciplined capital deployment positions us to drive significant value for physicians, patients and in turn, our shareholders.

我們擁有一支成熟的管理團隊，專注於策略、持續運營，並有嚴格的資本配置，這使我們能夠為醫生、患者以及股東創造巨大價值。

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

這樣，Sun 現在就可以更詳細地介紹我們的財務表現。太陽？

Thank you, Saum, and good morning, everyone. Our financial results in the third quarter continue to be strong with adjusted EBITDA coming in well above our guidance range. In the third quarter, we generated total net operating revenues of $5.1 billion and consolidated adjusted EBITDA of $978 million, a 15% increase over third quarter 2023.

謝謝你，Saum，大家早安。我們第三季的財務表現持續保持強勁，調整後的 EBITDA 遠高於我們的預期範圍。第三季度，我們創造了 51 億美元的總淨營業收入，合併調整後 EBITDA 為 9.78 億美元，比 2023 年第三季成長 15%。

Our third quarter adjusted EBITDA margin of 19.1% is up 220 basis points from third quarter of '23. These results were driven by strong same-store revenue growth, favorable payer mix and effective cost controls. I would now like to highlight some key items for each of our segments in the third quarter, beginning with USPI, which again delivered strong operating results.

我們第三季的調整後 EBITDA 利潤率為 19.1%，較 23 年第三季上升了 220 個基點。這些業績得益於強勁的同店收入成長、有利的付款人組合和有效的成本控制。現在，我想重點介紹一下第三季度我們各個部門的一些關鍵項目，首先是 USPI，它再次取得了強勁的營運業績。

USPI's adjusted EBITDA grew 19% over last year, with adjusted EBITDA margin at 38.5%. USPI delivered 8.7% increase in same-facility system-wide revenues over last year with same-facility system-wide net revenue per case, up 7.6%, driven by high levels of acuity and favorable payer mix. Same-facility system-wide cases grew 1%.

USPI 的調整後 EBITDA 較去年同期成長了 19%，調整後 EBITDA 利潤率為 38.5%。與去年相比，USPI 的同機構全系統收入成長了 8.7%，同機構全系統每例淨收入成長了 7.6%，這得益於高敏銳度和有利的付款人結構。同一設施全系統病例增加了 1%。

Turning to our hospital segment. Adjusted EBITDA grew 11% with margins up 180 basis points over last year at 13.5%. Excluding the divested hospitals, adjusted EBITDA in our hospital segment grew 24% over third quarter of '23.

談到我們的醫院部門。調整後 EBITDA 成長 11%，利潤率較去年同期上漲 180 個基點，達到 13.5%。除剝離的醫院外，我們醫院部門的調整後 EBITDA 比 23 年第三季增加了 24%。

Same-hospital inpatient admissions increased 5.2% and revenue per adjusted admission grew 3.3%, again demonstrating favorable payer mix and continued high acute levels. Our consolidated salary, wages and benefits were 43.3% of net revenues in the quarter, and our consolidated contract labor expense was 2.2% of SW&B, both substantially lower than the 45.2% and 3.1%, respectively, that we reported in third quarter of '23.

同一醫院的住院人數增加了 5.2%，每例調整後入院收入增加了 3.3%，再次證明了有利的付款人結構和持續的高急性病水準。本季度，我們的綜合薪資、薪資和福利佔淨收入的 43.3%，我們的綜合合約勞務費用佔 SW&B 的 2.2%，均遠低於 2017 年第三季報告的 45.2% 和 3.1%。

Next, we will discuss our cash flow, balance sheet and capital structure. We generated $829 million of free cash flow in the third quarter. And as of September 30, we had $4.1 billion of cash on hand with no borrowings outstanding under our $1.5 billion line of credit facility. We repurchased 795,000 shares of our stock for $124 million during the quarter. And year-to-date, we have repurchased 5.6 million shares for $672 million.

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。我們在第三季產生了 8.29 億美元的自由現金流。截至 9 月 30 日，我們手頭上有 41 億美元現金，並且在 15 億美元的信用額度下沒有未償還借款。我們在本季以 1.24 億美元回購了 795,000 股股票。今年迄今為止，我們已回購了 560 萬股，價值 6.72 億美元。

As Saum mentioned, our leverage ratio as of December 30 was 2.2 times EBITDA or 2.8 times EBITDA less NCI, a substantial improvement from year-end, reflecting the proceeds that we received from our hospital divestitures as well as our outstanding operational performance.

正如Saum 所提到的，截至12 月30 日，我們的槓桿率為EBITDA 的2.2 倍或EBITDA 減去NCI 的2.8 倍，較年底有大幅改善，反映了我們從醫院資產剝離中獲得的收益以及我們出色的營運表現。

Let me now turn to our outlook for 2024. For '24, we now expect consolidated net operating revenues in the range of $20.6 billion to $20.8 billion, $100 million lower at the midpoint versus our prior expectations due primarily to the sale of the Alabama hospitals. We are raising our 2024 adjusted EBITDA outlook range by $50 million to $3.9 billion to $4.0 billion reflecting the strong fundamental performance of our businesses, partially offset by the impact of the sale of our Alabama hospitals.

現在我來談談我們對 2024 年的展望。對於'24年，我們目前預計合併淨營業收入將在206億美元至208億美元之間，中間值比我們之前的預期低1億美元，主要原因是阿拉巴馬州醫院的出售。我們將 2024 年調整後 EBITDA 預期範圍上調 5000 萬美元，至 39 億美元至 40 億美元，這反映了我們業務強勁的基本表現，但部分抵消了出售阿拉巴馬州醫院的影響。

At the midpoint of our range, we now expect our full year '24 adjusted EBITDA to grow 12% over '23 or 20% when taking into account the impact of reduced EBITDA from divested facilities. At USPI, we have narrowed the range of our expected '24 adjusted EBITDA to $1.76 billion to $1.80 billion. And in the hospital segment, we are raising our '24 adjusted EBITDA outlook range by $50 million at the midpoint to $2.14 billion to $2.20 billion.

在我們範圍的中間點，我們目前預計 24 年全年調整後 EBITDA 將比 23 年增長 12%，如果考慮到剝離設施導致 EBITDA 減少的影響，則增長 20%。在 USPI，我們已將預期 24 年調整後 EBITDA 範圍縮小至 17.6 億美元至 18 億美元。在醫院部門，我們將 24 年調整後 EBITDA 預期範圍中位數上調 5,000 萬美元，至 21.4 億美元至 22 億美元。

Turning to cash flows. We now expect free cash flows in the range of $975 million to $1.225 billion. This range includes the payment of about $875 million in net taxes related to our completed divestitures, including the recent Alabama transaction.

轉向現金流。我們現在預計自由現金流將在 9.75 億美元至 12.25 億美元之間。這一範圍包括支付與我們已完成的資產剝離（包括最近的阿拉巴馬州交易）相關的約 8.75 億美元的淨稅。

Excluding these tax payments, this represents $1.975 billion of free cash flow at the midpoint of our '24 outlook or $1.225 billion of free cash flow less NCI, an increase of $50 million over prior expectations. As we've said before, the continued improvement in our cash flow performance has helped us deleverage our balance sheet while making disciplined investments in our business and delivering value for our shareholders.

不包括這些稅款，這代表我們 24 年展望中點的自由現金流為 19.75 億美元，或 12.25 億美元的自由現金流減去 NCI，比先前的預期增加了 5,000 萬美元。正如我們之前所說，現金流表現的持續改善幫助我們降低了資產負債表的槓桿率，同時對我們的業務進行了有紀律的投資並為股東帶來了價值。

Now I'd like to spend a minute discussing '25. We are still conducting our business planning processes and evaluating key assumptions, and therefore, it's premature at this point for us to provide specifics on '25 guidance.

現在我想花一點時間討論一下‘25。我們仍在進行業務規劃流程和評估關鍵假設，因此，目前提供有關『25 指引的具體資訊還為時過早。

However, we do want to give you some context for our current thinking about next year. First of all, there are two normalizing items that I would call out. We have reported $113 million of adjusted EBITDA in 2024 from facilities that we have divested and that will not recur in '25.

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。首先，我要指出兩個規範化項目。我們報告稱，2024 年調整後的 EBITDA 為 1.13 億美元，這些資金來自我們已剝離的設施，這些設施在 25 年不會再次出現。

In addition, we have reported $74 million of out-of-period favorable adjustments from supplemental Medicaid programs in Michigan and Texas in 2024. More than offsetting these two items at a consolidated level, we expect continued growth in same-store volumes and effective pricing, some potential additional revenue from Medicaid supplemental programs and continued strong operational efficiencies and disciplined cost controls.

此外，我們報告稱，2024 年密西根州和德克薩斯州的補充醫療補助計劃將帶來 7,400 萬美元的期外優惠調整。除了在合併層面上抵消這兩項因素的影響外，我們預計同店銷售和有效定價還將繼續增長，醫療補助補充計劃將帶來一些潛在的額外收入，並將繼續保持強勁的營運效率和嚴格的成本控制。

We also anticipate further contributions from recent investments in partnerships in the hospital segment as well as from an M&A and de novo development within USPI. We look forward to completing the planning process and sharing guidance with you for '25 in February of our earnings call.

我們也預計，最近對醫院部門的合作投資以及 USPI 內部的併購和全新開發將帶來進一步的貢獻。我們期待在 2 月財報電話會議上完成規劃流程並與您分享 25 年的指導。

And finally, as a reminder, our capital deployment priorities have not changed. First, we will continue to prioritize capital investments to grow USPI for M&A.

最後，提醒一下，我們的資本部署重點沒有改變。首先，我們將繼續優先考慮資本投資，以發展 USPI 的併購業務。

Second, we expect to invest in key hospital growth opportunities, including our focus on higher acuity service offerings.

其次，我們希望投資關鍵的醫院成長機會，包括我們對更高敏銳度服務產品的關注。

Third, we will evaluate opportunities to retire and/or refinance debt. And finally, we'll have a balanced approach to share repurchases, depending on market conditions and other investment opportunities. We consider our equity to be very attractive at the multiples at which it trades and see this as an opportunity to drive value for shareholders with our attractive free cash flow profile.

第三，我們將評估償還和/或再融資債務的機會。最後，我們將根據市場狀況和其他投資機會，採取平衡的方式進行股票回購。我們認為我們的股權在其交易倍數上非常有吸引力，並將此視為利用我們具有吸引力的自由現金流狀況為股東創造價值的機會。

In conclusion, we're extraordinarily pleased with our strong performance in '24 and the significant progress we have made with our portfolio transformation. We are confident in our ability to deliver on our increased outlook for 2024 as we remain focused on providing patient centered care in the communities we serve. And with that, we're ready to begin the Q&A. Operator?

總而言之，我們對 24 年的強勁表現以及投資組合轉型的重大進展感到非常高興。我們有信心，我們有能力實現我們對 2024 年更高的願景，因為我們將繼續專注於為我們服務的社區提供以患者為中心的護理。現在，我們準備開始問答環節。操作員？

(Operator Instructions)

（操作員指令）

Josh Raskin, Nephron Research.

喬希‧拉斯金 (Josh Raskin)，腎元研究公司。

Just a couple of quick clarifications. I think the ASC segment guidance for USPI implies a drop sequentially in EBITDA that would obviously be seasonally very unusual. So I'm just curious if there's anything to call out there. And I think cash flow, if you could just tell us what the total tax payments in 4Q are going to be.

只需快速澄清幾點。我認為 ASC 對 USPI 的分部指導意味著 EBITDA 將環比下降，這在季節性上顯然是非常不尋常的。所以我只是好奇是否有什麼值得注意的。我認為是現金流，如果您能告訴我們第四季度的總稅收是多少。

And then just my real question would be, could you just talk about changes or any changes that you're potentially seeing from managed care behavior?

那麼我真正的問題是，您能談談您在管理式醫療行為中可能看到的變化或任何變化嗎？

Okay. There's three questions there. So let's handle them. Why don't we start with the -- I don't think that's accurate on the USPI point. So let's just try to clarify that first and the tax payments, and I'll talk about managed care.

好的。這裡有三個問題。所以讓我們來處理它們。我們為什麼不從──開始呢？因此，我們先來澄清這個問題和納稅問題，然後我再談談管理式醫療。

Yes, Josh, this is Sun. For USPI EBITDA, we reported [$439 million] in Q3 and our guidance currently implies $500 million at the midpoint for USPI in Q4. So whatever -- what we see each year a Q4 upswing. In terms of tax payments -- .

是的，喬希，我是孫。對於 USPI 的 EBITDA，我們報告第三季的利潤為 [4.39 億美元]，而我們目前的預期是 USPI 在第四季度的中位數為 5 億美元。所以無論如何——我們每年都會看到第四季的上漲。在納稅方面--。

I was looking at growth rates, so I screwed up the question. Sorry about that.

我正在關注成長率，所以我搞砸了這個問題。很抱歉。

I see. Okay. on tax, as we put in our investor presentation, we have $875 million of total deal payments for the year, of which we expect to pay about $700 million in Q4, in addition with our kind of standard other tax payments.

我懂了。好的。關於稅收，正如我們在投資者報告中所述，我們今年的交易支付總額為 8.75 億美元，其中我們預計將在第四季度支付約 7 億美元，此外還有我們的標準其他稅收。

Josh, on the managed care side, I'll probably keep the comments limited to what dialogue has been around two topics. One is just the impact of the two midnight rule and particularly in the Medicare Advantage space. And secondly, I think there's been discussions about the impact of managed care denials.

喬希，在管理式醫療方面，我可能會將評論限制在圍繞兩個主題的對話範圍內。一是兩個午夜規則的影響，特別是在醫療保險優勢計劃領域。其次，我認為已經討論過管理式醫療拒絕的影響。

Look, when it comes to two midnight, I think the process of adopting fully adopting the guidance on the 2 midnight rule in the Medicare Advantage market is what I would describe as still underway. I don't think it's been fully adopted.

看，當談到午夜兩點時，我認為在醫療保險優勢市場全面採用午夜兩點規則指導的過程在我看來仍在進行中。我認為它尚未被完全採用。

At least for us, we have seen probably somewhere between 50 basis points and 100 basis points contribution to our overall admissions growth, but certainly short of and with more work than there should be if the 2 midnight rule was fully adopted. And I guess at some level, that goes back to this issue of disputes and denials and other things. I mean, again, I can only speak about us. We're very disciplined and clean and compliant in the way that we document and code.

至少對我們來說，我們已經看到對我們的整體招生成長的貢獻可能在50 個基點到100 個基點之間，但肯定少於完全採用2 點午夜規則所需的貢獻，而且需要做的工作也更多。我想，在某種程度上，這又回到了爭議、否認和其他問題。我再說一遍，我只能談論我們自己。我們在記錄和編碼方面非常嚴謹、清晰且合規。

And I do think that if you look at the last few years, the amount of activity that we've seen in the industry, increasing administrative costs on both sides for payers and providers related to disputes and denials has gone up in somewhat of an extraordinary way.

我確實認為，如果你看看過去幾年，我們看到這個行業的活動量，支付方和提供者雙方在爭議和拒絕方面的管理成本都在以某種非同尋常的速度增加。

And it's certainly frustrating if you're sitting on this side of that activity. And at the same time, we have made the right investments and have the right capabilities and processes inside of Conifer (for us) and our clients, to have mitigated that impact relatively on what's been happening in the industry. But at some point, there has to be a solution to this because it's really just wasted administrative time and cost.

如果你坐在這項活動的這一邊，那肯定會令人沮喪。同時，我們進行了正確的投資，並在 Conifer 內部擁有正確的能力和流程（對我們）和我們的客戶而言，從而相對減輕了對行業正在發生的事情的影響。但在某些時候，必須對此有一個解決方案，因為這實際上只是浪費管理時間和成本。

And Josh, this is Sun again. I think you also asked about USPI revenues sequentially. So Q3 was 11.39 for USP revenue and our guidance implies about [11.25] in Q4, so sequentially flat. I think two things. One is, it didn't change our USPI guidance, so we opted to leave both the EBITDA and revenues as they were. And then second, we also see, as you know, a pretty strong EBITDA margin increase in Q4. Again, historically, and we expect the same. So those are kind of the two pieces for the revenue and EBITDA guidance.

喬希，我又是孫先生。我想您也詢問了 USPI 的連續收入。因此，第三季的 USP 收入為 11.39，而我們的預期意味著第四季的收入約為 [11.25]，因此環比持平。我認為有兩點。一是，它沒有改變我們的 USPI 指導，因此我們選擇保持 EBITDA 和收入不變。其次，如您所知，我們也看到第四季度的 EBITDA 利潤率大幅成長。再一次，從歷史來看，我們也期望同樣的結果。所以這些就是收入和 EBITDA 指導的兩個部分。

Yes. And look, we have been more fortunate in our ability to plan and recover given what happened from the hurricane standpoint, we had 148 facilities impacted and at some point, shut down. Only one of them at this point is still shut down. And so what we have done, we're confident that we will work on bringing back that business in the fourth quarter.

是的。從颶風的角度來看，我們在規劃和恢復方面非常幸運，我們有 148 個設施受到影響並在某個時候關閉。目前其中只有一個仍處於關閉狀態。因此，我們有信心在第四季度恢復該業務。

We're confident that the margins will improve, and we've committed to our guidance for the year that we raised last quarter for USPI, and we're going to keep it for the fourth quarter and therefore, the full year from what we raised. And yes, it might make the numbers look slightly a little wonky there. But realize that we did have impact, but at the same time, we've made a decision that we think our operations will recover to the point where we'll be able to meet that guidance.

我們相信利潤率會提高，我們已承諾上個季度提高的 USPI 年度業績指引，並將在第四季度和全年保持這一指引。是的，它可能會讓這些數字看起來有點不穩定。但要意識到我們確實產生了影響，但同時，我們已經做出決定，我們認為我們的營運將恢復到能夠滿足該指導的程度。

Ben Hendrix, RBC Capital Markets.

加拿大皇家銀行資本市場 (RBC Capital Markets) 的 Ben Hendrix。

I was wondering if you could provide a little bit more detail on your 2025 comments, specifically around growth in SS volumes next year. Is that the degree to which you see those continuing to kind of outpace historical trends? Is there any moderation assumed in there? And just your general thoughts on that momentum.

我想知道您是否可以就 2025 年的評論提供更多細節，特別是有關明年 SS 數量增長的情況。您認為這些趨勢是否將持續超越歷史趨勢？其中是否假設有任何節制？您對這種勢頭的整體看法是什麼？

Yes. No, thank you. Good question for '25. We continue to see a strong demand environment. As we've talked about before, we do believe that the demand recovery, especially in the hospital segment, around the country continues as kind of the replacement of the early mortality that occurred from COVID in that demand environment.

是的。不，謝謝。對 '25 來說，這是個好問題。我們持續看到強勁的需求環境。正如我們之前談到的，我們確實相信，全國各地的需求復甦，特別是醫院領域的需求復甦，將會繼續，以替代在這種需求環境下因 COVID 而出現的早期死亡率。

And I don't know when that's going to slow down to a more normal range. But currently, we still see that robust demand environment. And at the same time, we've spent the year working on cost efficiently, expanding our capacity in order to accommodate that volume so that we're not doing it with expensive contract labor, which really is a testament to our work in nurse recruiting that we have done this year through many of the terrific relationships formed with schools around the country.

我不知道什麼時候這個速度才會減緩到比較正常的範圍。但目前，我們仍看到強勁的需求環境。與此同時，我們花了一年的時間提高成本效率，擴大產能以適應這一數量，這樣我們就不用昂貴的合約工了，這實際上是我們在護士招聘方面工作的證明今年我們與全國各地的許多學校建立了良好的關係，從而實現了這一目標。

And so I don't -- I can't sit here today and say that we're forecasting some kind of a decline as we look forward. I mean as we think about our operations, moving from the fourth quarter to the first quarter, we're not thinking about them differently at this point.

因此，我今天不能坐在這裡說，我們預測未來會出現某種衰退。我的意思是，當我們考慮我們的營運時，從第四季度到第一季度，我們目前並沒有以不同的方式考慮它們。

A.J. Rice, UBS.

A.J.賴斯、瑞銀。

Maybe I'll use Josh's approach. One clarification and then one question. Clarification being around the 1% USPI same-facility volume growth. That's a step-up from the first half. But you sort of alluded to maybe there was a little bit of impact from hurricanes in there. Just wondered if it was. And I know long term, you have a transition you're making towards higher acuity procedure that is helping on the revenue per case side but hitting a little on the volume side. Are you still in the midst of that? And what's the path to get back to 2% to 3%.

也許我會採用 Josh 的方法。先澄清一個問題，再提問一個問題。澄清一點，USPI 同一設施產量增加 1% 左右。這比上半場有了進步。但您似乎暗示那裡可能受到了一點颶風的影響。只是想知道是否如此。我知道，從長遠來看，您正在向更高敏銳度的程序轉變，這對每例收入有幫助，但對數量卻有一點影響。你仍處於這種狀態嗎？那麼回到2%到3%的途徑是什麼呢？

And then I just want to ask on your capital deployment. Thanks for laying the priorities there. But obviously, you're at a point where you've got strong free cash flow net, your debt is down to a pretty low level. So we're flipping around the discussion away from paying down more debt would say is there any to accelerate the pace of development in USPI to consider accelerated the buyback pace or even consider possibly a dividend or a larger deal out there?

然後我只想問一下你的資本部署狀況。感謝您在此列出優先事項。但顯然，您現在擁有強勁的自由現金流淨額，債務已降至相當低的水平。因此，我們的討論不再是償還更多債務，而是是否有任何措施可以加快 USPI 的發展速度，考慮加快回購速度，甚至考慮可能的股息或更大的交易？

Yes. Thanks, A.J. Just in terms of the clarification point, as we said at the beginning of the year, given the extraordinary comps from 2023, we thought we would move into positive volume territory later in the year, and that's kind of the pattern that you've seen, right, from Q1, Q2, Q3. We'll see what happens with Q4, given the point that I made in the prior question related to the hurricane impact.

是的。謝謝，A.J.就澄清點而言，正如我們在今年年初所說的那樣，鑑於 2023 年的非凡業績，我們認為我們將在今年晚些時候進入正銷量領域，這就是你所看到的模式，對，從Q1 、Q2、Q3。考慮到我在上一個問題中提到的颶風影響，我們將看看第四季的情況。

And yes, we continue to focus on growing acuity, which drives net revenue per case. It also drives extraordinary value in the system from an overall learning the cost of care standpoint. And we continue to look for opportunities where those transitions can happen in an orderly fashion to migrate certain lower acuity, higher volume type of activities out of the ASCs. I think that will continue for the next couple of years. As we had said from the beginning, it was a multiyear plan to kind of move some of those things out.

是的，我們將繼續致力於提高敏銳度，這將推動每個案件的淨收入。從整體學習護理成本的角度來看，它也為系統帶來了非凡的價值。我們將繼續尋找機會，讓這些轉變能夠有序地進行，以便將某些較低敏銳度、較高容量類型的活動從 ASC 中遷移出來。我認為這種情況將在未來幾年持續下去。正如我們一開始所說的那樣，這是一個多年計劃，目的是將其中一些東西搬走。

Look, you're right about capital deployment. Obviously, we're very cognizant of the free cash flow generation looking forward. One clarification, obviously, given the cash we have on our balance sheet, we've delivered, but the debt paydown opportunities are still ahead of us, which Sun and team will structure in very much the right way.

看，你關於資本部署的說法是對的。顯然，我們非常清楚未來的自由現金流的產生。顯然，需要澄清的是，考慮到我們資產負債表上的現金，我們已經實現了目標，但是債務償還機會仍然擺在我們面前，孫正義和團隊將以正確的方式構建這一機會。

The second point I would make is despite our guidance, if you look at our history for the last five or six years, even before being in this vision, we've deployed more than our "200 to 250" in capital in the USPI given the larger deals that we've done, including the deal that we did in the first quarter of this year for 45 ASCs, plus what we've done otherwise.

我想說的第二點是，儘管我們有指導方針，但如果你回顧我們過去五、六年的歷史，即使在實現這一願景之前，我們已經在USPI 中投入了超過「200 到250」的資本，因為我們已完成的大型交易，包括今年第一季完成的 45 筆 ASC 交易，以及我們已完成的其他交易。

And so we continue to believe accelerating spend at USPI is the single most accretive thing to creating value within the company. And of course, as I noted in my comments and Sun in his, we have, in fact, accelerated relative to the trend over the last few years, given our deleveraging and cash positions our ability to return value back to shareholders.

因此，我們仍然相信，加速 USPI 的支出是公司內部創造價值的唯一最增值的事情。當然，正如我在我的評論和孫正義在他的評論中提到的那樣，考慮到我們的去槓桿和現金狀況以及我們向股東返還價值的能力，我們實際上相對於過去幾年的趨勢已經加速發展。

So we -- I think they're very consistent. Your points are very consistent with our comments with the helpful added nuance that we have the flexibility to be more proactive and aggressive on each one of those dimensions at this point looking forward.

所以我們—我認為他們非常一致。您的觀點與我們的評論非常一致，並且還有一個很有幫助的補充，那就是我們可以靈活地在每個方面都採取更積極主動和更積極的措施。

Stephen Baxter, Wells Fargo.

富國銀行的史蒂芬‧巴克斯特。

I wanted to ask another one about the fourth quarter. I guess the hospital earnings cadence is a little different this year than we probably would have expected. Usually, hospital EBITDA is generally up in the fourth quarter versus the third quarter. It seems like you guys are guiding to a bit of a different cadence.

我想再問一個關於第四季的問題。我想今年醫院的獲利節奏可能與我們預期的有些不同。通常，醫院的 EBITDA 在第四季度會比第三季度上升。看起來你們正在引導一種略有不同的節奏。

So just wondering if you could help us ridge that. And then if there's anything unusual in the third quarter either positive or negative in the hospital business that we should be keeping in mind?

我只是想知道您是否可以幫助我們解決這個問題。那麼，如果第三季醫院業務出現任何異常情況，無論是積極的還是消極的，我們都應該注意嗎？

I mean, Sun can go through the numbers. But look, first of all, I think it's a very small change. I mean, first, we have a divestiture in there. That's the biggest thing. And the second thing is just from a seasonality standpoint, that's less pronounced in the hospitals than you would see in the USPI ambulatory surgery business.

我的意思是，孫正義可以仔細研究這些數字。但首先，我認為這是一個非常小的變化。我的意思是，首先，我們在那裡進行了資產剝離。這才是最重要的事。第二件事是從季節性的角度來看，醫院的季節性不如 USPI 門診手術業務那麼明顯。

But look guys, there's a range there for a reason with upside to the range. And let's look at the trajectory of this year, it is obviously our goal on what may be a bit conservative there to continue to outperform. But I don't know if you want to address specific numbers.

但各位，你們看看，這個範圍是有原因的，而且這個範圍還有上升空間。讓我們看看今年的發展軌跡，顯然，我們的目標可能有些保守，但仍然希望取得優異表現。但我不知道您是否想討論具體的數字。

Yes, I'll do a little bit. I think, Steve, last year, if you kind of look at our quarterly progression, our Q4 was up. But if you recall, we had about a $52 million out of period from California and tax that we called out. once you kind of normalize for that, it was fairly steady throughout the quarters.

是的，我會做一點。史蒂夫，我認為，如果你看去年我們的季度進展，你會發現我們的第四季業績是上升的。但如果你還記得的話，我們從加州獲得了約 5,200 萬美元的稅金。一旦將其正常化，它在整個季度中都會相當穩定。

This year, if you look at our quarterly progression, we again had obviously, the HRA from Michigan out-of-period piece in Q1. We also called out an out-of-period $30 million from Texas Q2. So there's a bit of lumpiness in that.

今年，如果您查看我們的季度進展，我們顯然再次獲得了第一季來自密西根的 HRA 期外部分。我們也從德州第二季獲得了 3000 萬美元的非定期貸款。這其中存在一些不平衡之處。

But we think our Q4 guidance is pretty consistent with our overall commentary on good margins, very well-managed operating cost and a good demand environment. And then the last part of your question, in Q3, we did not have any out-of-period or kind of onetime things that we are calling out.

但我們認為，我們的第四季指引與我們對良好利潤率、管理良好的營運成本和良好的需求環境的整體評價非常一致。然後是你問題的最後一部分，在第三季度，我們沒有任何超出期外或一次性的事情需要注意。

Ann Hynes, Mizuho.

安海因斯（Ann Hynes）、瑞穗（Mizuho）。

Can you let us know just a supplemental payment amount in Q3 this year versus last year? And heading into 2025, you called out $187 million of EBITDA you have to -- overcome, but I believe you said you've -- can you just confirm that you think you can offset that? And I think you said partly because of some of the Medicaid programs and strong volume growth and maybe highlight what you think could be incremental Medicaid payments in 2025.

您能告訴我們今年第三季與去年相比的補充付款金額嗎？而進入 2025 年，您提到您必須克服 1.87 億美元的 EBITDA，但我相信您說過您已經——您能否確認您認為您可以抵消這一損失？我認為您所說的部分原因是一些醫療補助計劃和強勁的數量增長，也許可以強調一下您認為 2025 年醫療補助支付可能會增加。

Ann, it's Sun. Year-to-date in '24, we'll be at about almost $900 million of Medicaid supplemental fees year-to-date. The comparison to '23 becomes a little bit tricky because of all the divestitures in same-store hospital metrics. So we can maybe work with you off-line on that?

安，我是孫。從 24 年開始，我們的醫療補助補充費用就已經接近 9 億美元。由於同店醫院指標的所有剝離，與 23 年的比較變得有點棘手。那我們可以線下與您合作嗎？

And then, yes, in my commentary, we called out $113 million plus another $74 million from hospital divestitures and out-of-period Medicaid payments that we believe currently at this stage that we can more than offset at consolidated level through all the various things that we discussed.

然後，是的，在我的評論中，我們提到了1.13 億美元，再加上醫院資產剝離和超出期限的醫療補助支付的7400 萬美元，我們認為目前在這個階段，我們可以通過各種方式在合併水準上抵銷這些損失。

On your question about supplemental payments for next year. I think it's too early to have specific comments. We're all aware of potential new programs in certain markets that we're all monitoring closely, and we're awaiting final decisions. So we'll obviously update as we find out more about that.

關於您關於明年補充支付的問題。我認為現在發表具體評論還為時過早。我們都知道某些市場可能會有新的計劃，我們都在密切關注，並等待最終的決定。因此，當我們發現更多相關資訊時，我們會及時更新。

Michael Ha, Baird.

麥可·哈，貝爾德。

So, I see your hospital average on the day, I think it's the first time you've improved below five days number of three years. I was wondering if you could talk about what it will take to operationally get back to sort of pre-COVID levels, your expected time line, how we should think about the earnings benefit for hospital segment growth and margin expansion.

所以，我看了您當天的住院平均時間，我認為這是您三年來第一次好轉時間少於五天。我想知道您是否可以談談如何在營運上恢復到疫情之前的水平，您預計的時間表，以及我們應該如何考慮醫院部門成長和利潤率擴大帶來的獲利效益。

And then in terms of the inpatient admin strength, I was wondering if you could sort of parse out the sources of that strength and the durability of that going forward.

然後，就住院管理實力而言，我想知道您是否可以分析出這種實力的來源以及未來的持久性。

Well, on the length of stay piece, I appreciate you're calling out the improvements that we've made. This has been our initiatives in length of stay management, which started in a new fresh form in 2022 and '23 in order to manage contract labor, excess contract labor costs have continued in this environment because we think it's important, and we're pleased with the results we're getting there.

好吧，關於住宿時間長度，我很感謝您對我們所做的改進表示讚賞。這是我們在工齡管理方面的舉措，該舉措於2022 年和2023 年以新形式開始實施，目的是管理合約工，在這種環境下，超額合約工成本仍在繼續，因為我們認為這很重要，我們很高興我們已取得成果。

But I would make a comment similar to kind of my comments in the past about we don't spend a lot of time trying to chase the exact mix and volume that we had pre-COVID. I mean the same thing is true in length of stay, right? As our acuity goes up, you would expect length of stay to increase a bit from pre-COVID acuity levels and therefore, lengths of stay that were a bit lower.

但我想發表與我過去的評論類似的評論，即我們不會花費大量時間去追逐與 COVID 之前完全相同的組合和數量。我的意思是，停留時間也是一樣的，對嗎？隨著我們的敏銳度上升，您會預期住院時間會比 COVID 之前的敏銳度水平略有增加，因此住院時間會略有縮短。

So our fundamental driver strategically in the business is to continue to build our high acuity business which we think is uniquely suited and sustainable to get to your second point, from a demand standpoint, durable in terms of inpatient admissions. And within the context of taking care of those patients appropriately, we look to optimize length of stay relative to metrics that are out there like geometric mean and other things.

因此，我們在業務上的根本戰略驅動力是繼續建立我們的高敏銳度業務，我們認為該業務具有獨特性和可持續性，可以從需求的角度實現你的第二點，即住院治療方面的持久性。在適當照顧這些患者的背景下，我們希望根據現有的幾何平均值等指標來優化住院時間。

Look, on the broader comment, I will just echo what I said earlier in the call, which is we're pleased with the demand environment today. We feel positive about it looking forward and even into 2025. As I said, I don't -- we're not planning differently for the first quarter next year versus the last quarter of this year in terms of a robust demand environment.

你看，關於更廣泛的評論，我只會重複我在電話會議早些時候所說的話，那就是我們對今天的需求環境感到滿意。我們對此抱持樂觀的態度，展望未來，甚至展望 2025 年。正如我所說，就強勁的需求環境而言，我們對明年第一季和今年最後一季的計畫沒有什麼不同。

We're not seeing signs or signals that we should stop looking to add capacity selectively in markets where that demand could be serviced in an appropriate cost structure, et cetera. So, I feel pretty good about that. The inpatient and hospital-based demand strength is really -- it's both urgent and we're seeing nice success in some of our critical service lines, cardiovascular and other, in particular, specialty surgical areas. So the drivers are both urgent and elective business.

我們沒有看到任何跡像或訊號表明我們應該停止在能夠以適當的成本結構滿足需求的市場上選擇性地增加產能，等等。所以，我對此感覺很好。住院和醫院的需求強度確實很緊迫，而且我們在一些關鍵服務線、心血管和其他特別是專科外科領域看到了良好的成功。所以司機既需要緊急服務，也需要選擇性服務。

Payer mix obviously has been very helpful this year driven very much so by commercial and even more significantly by exchange strength. And that goes to not only the market, but our contracting strategy, which has been very inclusive of being in a broad range of exchange networks.

付款人組合今年顯然非常有幫助，這在很大程度上是由商業推動的，更重要的是由於交易所實力。這不僅適用於市場，也適用於我們的承包策略，涵蓋範圍非常廣泛，涵蓋各種交換網路。

Pito Chickering, Deutsche Bank.

德意志銀行的 Pito Chickering。

Medical admissions has continued to outpace surgical admissions. So how durable do you think that is? Or is it get past a Medicaid determination, do you think that surgical admissions normalize next year as comps get easier. And then a quick verification on hurricanes. You talked about the facilities impacted. Did you quantify a revenue impact from hurricanes in the fourth quarter?

內科入院人數一直超過外科入院人數。那麼您認為它的耐用性如何？或者是通過了醫療補助的決定，您是否認為隨著補償變得更加容易，明年外科手術入院人數會正常化。然後對颶風進行快速驗證。您談到了受影響的設施。您是否量化了第四季颶風對收入的影響？

Yes, Pito, we're going to have to ask you to repeat the first question in a second. But I would just -- rather than us spending time focused on the details of the hurricane impact. Look, we had 148 centers affected. We've got all but one running. We're expecting fourth quarter, higher acuity, better mix, therefore, better margins, and we're maintaining our commitment to our guidance that we raised at the end of the second quarter. The first question got -- it's either the connection or something, it was a little bit jumbled. Do you mind repeating that one more time for us?

是的，Pito，我們必須請你馬上重複第一個問題。但我只是想——而不是讓我們花時間關注颶風影響的細節。你看，我們有 148 個中心受到影響。除一個以外，其餘均已運行。我們預計第四季度的敏銳度更高，產品組合更好，因此利潤率更高，而且我們將繼續堅持第二季末提出的指導方針。第一個問題是——它要么是連接要么是別的什麼，有點混亂。您介意再給我們重複一遍嗎？

Yes. You bet. Apologies. I'm in a hotel room. Medical admissions continue to outpace surgical admissions this quarter. How durable is that. Or do you think as we get past Medicaid reiteration, do you think that surgical admissions accelerate next year as comps get easier after this year's Medicaid determination?

是的。當然。抱歉。我在飯店房間裡。本季度，內科入院人數持續超過外科入院人數。那有多耐用呢？或者您認為，隨著我們度過醫療補助重申期，您是否認為明年外科手術入院人數將會加速，因為在今年的醫療補助決定之後補償變得更加容易？

Yes. Got it. Okay. Well, yes, the medical admissions are reflective of two things. Obviously, one is just our continued commitment to emergency department excellence in terms of services, wait times and receiving ability from that standpoint, including how we manage our house to avoid our facilities ever being on diversion as a commitment to the community. We also have improved our ability to receive transfers from other hospitals for sick patients, intensive care patients which result in medical admissions oftentimes from outlying hospitals.

是的。知道了。好的。嗯，是的，醫療入院情況反映了兩件事。顯然，一是我們對急診服務、等待時間和接收能力等方面的卓越表現的持續承諾，包括我們如何管理我們的設施以避免我們的設施被轉移，這是對社區的承諾。我們也提高了從其他醫院轉診病人、重症監護病人的能力，這些病人往往需要從週邊的醫院入院。

And so we're not surprised by that. I mean this is -- again, fundamentally, these priorities are part of our strategy to continue to build and grow high acuity, elective and emergent care, including in the medical cases. I would also point out that medical admissions, not just surgical admissions have been pretty strong in the commercial environment, including for exchange participants.

因此我們對此並不感到驚訝。我的意思是——從根本上來說，這些優先事項是我們繼續建立和發展高敏銳度、選擇性和緊急護理（包括在醫療病例中）的策略的一部分。我還要指出的是，在商業環境中，醫學招生（不僅僅是外科招生）一直相當強勁，包括對於交易所參與者而言。

And of course, that raises the question of both the exchange growth impact, but also some utilization benefit that comes from exchange -- new exchange participants picking up more attractive coverage.

當然，這不僅引發了對交易所成長影響的問題，也引發了來自交易所的一些利用效益的問題——新的交易所參與者獲得了更具吸引力的覆蓋範圍。

Justin Lake, Wolfe Research.

賈斯汀·萊克（Justin Lake），沃爾夫研究公司。

First, a quick follow-up on '25. I just want to make sure I heard correctly that with all the puts and takes and the headwinds in terms of the year-over-year comp, you still expect to grow EBITDA year-over-year? And then my real question is on leverage. Now that you've completed the deal, I was wondering if you could share a target leverage ratio you expect to get to once you deploy the capital? And if you aren't ready to share that now, any thoughts on when you might be able to communicate that number.

首先，快速跟進一下‘25’。我只是想確保我聽到的沒有錯誤，考慮到去年同期的所有利弊和不利因素，您仍然預計 EBITDA 會同比增長嗎？我真正的問題是關於槓桿。現在您已經完成交易，我想知道您是否可以分享您在部署資本後預計達到的目標槓桿率？如果您現在還沒有準備好分享這個數字，那麼什麼時候可以告知這個數字呢？

Yes. Justin, just two real quick answers. The first is, yes, I think Sun's comments that we expect to more than offset normalized numbers. And we'll go through a full description of the puts and takes, obviously, when we provide guidance. But at this stage, our work indicates that we should more than offset that.

是的。賈斯汀，只需快速回答兩個問題。首先，是的，我認為孫正義的評論將超出我們預期的正常化數字。顯然，當我們提供指導時，我們將全面描述利弊。但現階段，我們的工作表明，我們應該更多地抵消這一點。

We're not ready to -- I mean, I think my comments in the leverage section around we are pleased with where we are from a leverage standpoint is probably the most that we're going to say at this stage rather than having a formal guidance number, but I think you can read into that, that we're pleased with where we are from that standpoint. And again, our -- my commentary on debt paydown still stands, which is working through the best ways to do that is something that we're actively in the midst of doing.

我們還沒有準備好——我的意思是，我認為我在槓桿部分的評論，我們對槓桿的現狀感到滿意，這可能是我們現階段要說的最多的話，而不是正式的指導數字，但我想你可以讀懂，從這個角度來看，我們對目前的狀況感到滿意。再次強調，我關於償還債務的評論仍然有效，即努力尋找最佳方法來償還債務，這是我們正在積極做的事情。

Joanna Gajuk, Bank of America.

美國銀行的喬安娜‧加朱克 (Joanna Gajuk)。

I guess the follow-up I would have on capital deployment comments around the ASC acquisitions. Any commentary there in terms of multiples? Or is there more competition or less in terms of what you end up paying for these deals when it comes to multiples? And are there larger assets to be acquired? I mean, it sounds like maybe there will be there.

我想我會對 ASC 收購的資本部署發表後續評論。關於倍數有什麼評論嗎？或者，當涉及到多重交易時，就您最終為這些交易支付的費用而言，競爭是更多還是更少？還有更大的資產可以收購嗎？我的意思是，聽起來也許會有。

But the other actual question, I guess, on the guidance for this year. The hospital revenue guidance was reduced by $100 million, call it, the midpoint. So I assume this is the Alabama Hospital. So -- but there's also higher, I guess, same-store inpatient admissions. And I don't want to bring up the hurricanes again, but just to make sure, was there any impact from hurricanes in Q4 that you had assuming here, too?

但我想，另一個實際問題是關於今年的指導。醫院收入預期減少了 1 億美元，可以說是中間值。所以我猜測這是阿拉巴馬醫院。所以 — — 但我猜同店住院人數也會比較高。我不想再提起颶風，但為了確保起見，您是否也假設第四季的颶風會產生影響？

We'll split up the questions here. The ASC business capital deployment and really the question being about multiples I would just step back and remind the audience, we're focused on our post-synergy multiples. And because of our ability, collectively, in the organization to drive to better management, more efficiency, network inclusion, supply chain efficiencies, et cetera, we often are able to buy assets and reduce the effective multiple within the first couple of years from that standpoint. And we're -- again, we're focused on what the effective multiple is at the end of that period rather than what we're paying for it.

我們將在這裡分開回答這些問題。ASC 商業資本部署以及真正的關於倍數的問題，我想退後一步並提醒觀眾，我們專注於協同效應後的倍數。由於我們整個組織能夠共同推動更好的管理、更高的效率、網路包容性、供應鏈效率等，我們通常能夠在購買資產後的頭幾年內降低有效倍數。而我們 — — 再次強調，我們關注的是該期間末的有效倍數，而不是我們為此付出的代價。

Now actually speaking, we have not seen changes in the purchasing multiples of any note recently. I know this question comes up from time to time. We have not seen any type of changes. And so we are consistently guiding to the same pre and post-acquisition multiples that we have in the past. And that's a good thing in terms of the availability of attractive high-quality assets that are choosing to become part of the USPI portfolio.

實際上，我們最近沒有看到任何票據的購買倍數發生變化。我知道這個問題時常會出現。我們沒有看到任何類型的變化。因此，我們始終如一地引導與過去相同的收購前後倍數。這對於選擇成為 USPI 投資組合一部分的有吸引力的高品質資產的可用性來說是一件好事。

Do you want to cover the hospital, hurricane?

你想覆蓋醫院嗎，颶風？

Joanna, on our hospital revenues, we still believe good demand environment, good pricing environment, high equity, all those things that we've talked about. Our Q4 revenue guidance, the reduction is all primarily driven by the divested hospitals, and we don't have any material impact in there for any hurricanes.

喬安娜，就我們醫院的收入而言，我們仍然相信良好的需求環境、良好的定價環境、高股權以及我們所談論的所有這些事情。我們的第四季收入預期減少主要是由於剝離醫院業務所致，颶風不會對我們造成任何重大影響。

Whit Mayo, Leerink Partners.

惠特·梅奧（Whit Mayo），Leerink Partners 合夥人。

So I'm just curious with the size of the acute care portfolio, obviously, much smaller than in the past. How are you thinking about the underlying infrastructure and cost that you need to support the business going forward? And I had just one other quick one, you didn't call out any of the ongoing accretion to Conifer from the hospital sales as an offset in '25. So I just was hoping you could address that.

所以我只是對急性護理組合的規模感到好奇，顯然比過去小得多。您如何考慮支援未來業務所需的基礎設施和成本？我還有另一個簡單的問題，您沒有指出 25 年醫院銷售對 Conifer 的持續增長作為抵消。所以我只是希望你能解決這個問題。

Okay. With one more time, the second part of that, the offset?

好的。再說一次，第二部分，偏移量？

Well, the accretion that you're getting to Conifer from the hospital sales considering you don't eliminate the earnings and the reporting going forward. Just [to say] an ongoing offset as we think about '25.

好吧，考慮到您不會消除未來的收益和報告，您將從醫院銷售中為 Conifer 帶來增量。只是[說]當我們思考'25時，會有一個持續的抵消。

Right. Yes. Okay. Got it. So let's start with the size of the acute care portfolio. Obviously, it's been reduced, and we would typically, on an ongoing basis, make adjustments, obviously, to the corporation from that perspective.

正確的。是的。好的。知道了。因此，讓我們先從急性護理組合的規模開始。顯然，這個數字已經減少了，而且我們通常會從這個角度持續對公司進行調整。

Remember, in the period after divestitures, we tend to have transition service agreements that support the divested hospitals for a significant period of time. And so the way we think about these things is that we ought to support those transition hospitals with our sales partners very thoroughly and differently than if we were owning them and that's not the least of which because we also have some longer-term Conifer relationships with these folks. So out of respect to what we do there, we take that job very seriously. And again, I would just reiterate that we are cognizant of the opportunity there overall from that standpoint.

請記住，在資產剝離後的一段時間內，我們傾向於簽訂過渡服務協議，以便在相當長的時間內為被剝離的醫院提供支援。因此，我們考慮這些事情的方式是，我們應該與我們的銷售合作夥伴一起非常徹底地、以不同於我們擁有這些醫院的方式支持這些過渡醫院，這並非最不重要的一點，因為我們還與一些長期的Conifer 關係這些人。因此，出於對我們在那裡所做工作的尊重，我們非常認真地對待這項工作。我再次重申，從這個角度來看，我們總體上認識到了那裡的機會。

Obviously, there are costs that are simply direct allocations to these markets that go away as part of what we sold. I mean, that's not surprising, the chassis certain purchase services contracts and other things would come down naturally as you would expect with asset sales.

顯然，有些成本只是直接分配給這些市場，而這些成本已作為我們銷售產品的一部分消失。我的意思是，這並不奇怪，底盤的某些購買服務合約和其他東西會像你預期的資產銷售一樣自然下降。

On the offset, Sun.

另一方面，太陽。

Yes. On Conifer, yes, as you noted, and as Saum has discussed several times before, we have long-term revenue cycle relationships with a lot of our divested sites. Going to '25, we do expect those to be a benefit to us. In terms of actual specifics, again, we'll have more information when we give our guidance to '25, but that is part of our overall expectations.

是的。關於 Conifer，是的，正如您所提到的，並且正如 Saum 之前多次討論過的，我們與許多剝離的站點建立了長期的收入周期關係。展望25年，我們確實期望這些能為我們帶來好處。就實際細節而言，當我們給出 25 年的指導時，我們會提供更多信息，但這是我們整體預期的一部分。

Andrew Mok, Barclays.

巴克萊銀行的 Andrew Mok。

Maybe if I could just follow up on that last question first. I understand that in cases where you expand the relationship of Conifer, there would be an incremental contribution to EBITDA. But if you do not expand the relationship, are you saying that there's still an incremental enterprise EBITDA contribution from those divestitures?

也許我可以先回答最後一個問題。我理解，如果擴大與 Conifer 的關係，EBITDA 的貢獻就會增加。但如果您不擴大關係，您是否說這些資產剝離仍會為企業帶來增量 EBITDA 貢獻？

Yes. Andrew, no, you're right. It's the expanded opportunities that we're mostly referencing in terms of '25 factors.

是的。安德魯，不，你是對的。我們在「25 個因素」中主要提到的是擴大的機會。

Yes. And the other thing, I don't mind calling out, look, there's -- we've talked about some of the expansion opportunities. One of them in particular will be larger than others, which will require us to take on a significant amount.

是的。另一件事，我不介意說出來，看，我們已經討論了一些擴張機會。其中一個項目的規模比其他項目大，這就需要我們承擔相當大的金額。

So I would think about that almost as a new customer acquisition in terms of what the margin profile would look like for Conifer in the outside market and again, as Sun said, we'll put more detail to that as we give 2025 guidance. But we will make investments in order to onboard that business in 2025 before getting to our overall typical performance with Conifer over time.

因此，就 Conifer 在外部市場的利潤率狀況而言，我認為這幾乎是一次新客戶的收購，正如孫正義所說，我們將在提供 2025 年指引時對此進行更詳細的說明。但我們將在 2025 年進行投資，以便開展該業務，然後才能隨著時間的推移使 Conifer 達到我們整體的典型表現。

I would say, for the rest of the divestitures, the expansions that we've done are a little bit more straightforward to onboard from that perspective. But it's a great story for Conifer in terms of these expansions.

我想說，對於其餘的資產剝離來說，從這個角度來看，我們所做的擴張會更直接。但從這些擴展的角度來看，這對 Conifer 來說是一個偉大的故事。

Brian Tanquilut, Jefferies.

傑富瑞 (Jefferies) 的 Brian Tanquilut。

Congrats on the quarter. Saum, in your prepared remarks, you talked a little bit about efficiency opportunities that you still see in the business. So as we think about the hospital segment and where margins stand today and with the divestitures that you've done, how much runway do you think you have left for margins? Or is it right to think that 15% segment level EBITDA is about the right side?

恭喜本季取得佳績。索姆，在您準備好的發言中，您談到了您在業務中仍然看到的效率機會。那麼，當我們考慮醫院部門以及當前的利潤率狀況以及您所做的資產剝離時，您認為還剩下多少利潤空間？或者說，認為 15% 的分部水準 EBITDA 是大致正確的？

Well, I think without getting into specific numbers, I mean, from efficiency opportunity standpoint, one of the things that we are focused on including being a little bit different than some others is capacity utilization, especially in high-value real estate in the hospitals, right?

嗯，我認為，不談具體數字，我的意思是，從效率機會的角度來看，我們關注的事情之一，包括與其他一些公司略有不同的是產能利用率，特別是在醫院的高價值房地產方面， 正確的？

And our ability to continue to improve the capacity utilization of our facilities for us represents -- just to give you one example, represents how we think about that ongoing efficiency opportunity. And so we're not -- again, our mindset is not, whatever the number is, to be satisfied with what the margins look like today.

我們持續提高設施產能利用率的能力代表著——僅舉一例，代表我們如何看待持續的效率機會。因此，我們不會—再說一次，無論數字是多少，我們的想法是不會滿足於今天的利潤率。

Obviously, ongoing improvements in labor supplies and other expenses, third-party purchase services, et cetera, stabilization of the staffing environment, the physician staffing environment, et cetera, all present opportunities looking forward to continue to try to optimize the business. But I would say that, as an example, that area of capacity utilization is still an important one to us from the standpoint of finding more efficiency.

顯然，勞動力供應和其他費用、第三方採購服務等方面的持續改善、人員配備環境的穩定、醫生人員配備環境等方面的持續改善，都為繼續嘗試優化業務提供了機會。但我想說，舉個例子，從提高效率的角度來看，產能利用率這個領域對我們來說仍然很重要。

Matthew Gillmor, KeyBanc Capital Markets.

馬修·吉爾摩（Matthew Gillmor），KeyBanc 資本市場。

I wanted to hit on the total joint replacement growth at USPI. I think you're up 19% this quarter and if we look at your disclosures, there was sort of an acceleration into the sort of 20% range starting last year and sustaining. So just wanted to see if you have any perspective to share with respect to the sustainability of that level of growth and maybe how that ties into your development pipeline on the USPI side.

我想要了解 USPI 整體關節置換的成長。我認為本季度你們的銷售額增長了 19%，如果我們看一下你們的披露信息，就會發現從去年開始銷售額就加速增長到了 20% 左右，並且這種趨勢一直持續。所以只是想看看您是否有任何關於這種增長水平的可持續性的觀點可以分享，以及這與 USPI 方面的發展渠道有何關聯。

Well, I think that -- I mean it's no secret that sometime around 2020, we -- or even before, we made a decision that we wanted to be the unquestionable leaders in outpatient bone and joint care, more broadly, bone, joint, spine, et cetera, with a full range of outpatient-based services.

嗯，我認為——我的意思是，在2020 年左右，甚至更早的時候，我們就做出了一個決定，我們想要成為門診骨關節護理領域無可爭議的領導者，更廣泛地說，骨關節，脊椎等，提供全方位的門診服務。

We believe and I think what we're seeing is that we can provide those services in a high-quality manner at a lower cost than in other settings. And I think that the industry has moved pretty heavily towards outpatient-based care.

我們相信，而且我認為，我們看到的是，我們可以以比其他環境更低的成本，高品質地提供這些服務。我認為該行業已大幅轉向門診治療。

Some of that care is still in the hospital outpatient-based environment versus in the freestanding environment. We still think there's migration opportunity over the next few years into the freestanding environment.

部分護理仍是在醫院門診環境中進行，而非在獨立環境中進行。我們仍然認為未來幾年存在著向獨立環境的遷移機會。

Obviously, with the burden of chronic illness that we see in the country today, there are people that will need hospital-based outpatient services simply because of chronic condition management and appropriately providing those services. But the reality is with all of these things that move into a lower cost, higher service setting, it's not a direct cannibalization.

顯然，鑑於當今國家慢性病負擔，有些人僅僅因為慢性病管理和適當提供這些服務就需要醫院門診服務。但實際情況是，隨著所有這些事物轉向成本更低、服務更高的環境，這並不是直接的蠶食。

The market expands and the market has been expanding for these services when you can offer it in an ambulatory setting. And so we're focused on that more than anything else is continuing to expand the marketplace, continuing to get younger and younger orthopedic surgeons who aren't exposed to ASCs in their training exposed to ASCs earlier in their careers to show them that this is a very viable place to practice.

當您可以在門診環境中提供這些服務時，市場就會擴大（而且這些服務的市場一直在擴大）。因此，我們最關注的是繼續擴大市場，繼續讓越來越年輕的骨科醫生在職業生涯早期接觸 ASC，讓他們知道這是一個非常適合練習的地方。

Sarah James, Cantor Fitzgerald.

莎拉詹姆斯 (Sarah James)，費茲傑拉領唱者。

Ambulatory 2024 guide shifted about 100 basis points to 150 basis points to be more revenue per case than volume compared to the 2Q 2024 guide. So is this how we should think about mix going forward with revenue per case being the larger driver compared to volume given your comments on the durability of trends around commercial mix and migration of low acuity out of ASC.

與 2024 年第二季的指引相比，2024 年門診指引調整了約 100 個基點至 150 個基點，每例收入高於治療量。那麼，考慮到您對商業組合趨勢的持久性以及低敏銳度從 ASC 遷移的評論，我們是否應該這樣考慮未來的組合，其中每例收入是比數量更大的驅動力。

And then just a quick clarification. On the year-to-date DPP, what's the mix between ambulatory and hospital. We're just trying to get to a clean revenue per case number?

然後只是快速澄清一下。關於今年迄今為止的 DPP，門診和醫院的混合情況如何。我們只是想獲得每個案件的明確收入？

Thanks for the question. We'll split them up again. But I think on the first question, look, there's a couple of things here that are important to put into perspective. First of all, I think that guidance is relevant for the rest of '24, right. We haven't said anything about '25 and how we're thinking about that with respect to our business planning.

謝謝你的提問。我們將再次把它們分開。但我認為，對於第一個問題，這裡有幾件事需要認真考慮。首先，我認為該指導與 24 年剩餘時間相關，對吧。我們還沒有透露有關‘25’的任何信息，以及我們如何根據業務規劃考慮這個問題。

And I understand there's a lot of puts and takes. I mean one of the reasons we're really pleased with the net revenue per case growth in the acuity growth USPI is because remember, we added 45 centers and more than that this year, but that 45 center tranche that was heavily non-orthopedic at the beginning of the year, and therefore, had lower average net revenues per case than in a truly orthopedic dedicated center.

我也知道這其中有很多得失。我的意思是，我們對USPI 敏銳度成長中每例淨收入的成長感到非常滿意的原因之一是，記住，我們今年增加了45 個中心，甚至更多，但那45 個中心部分主要是非骨科的因此，其每例的平均淨收入低於真正的專業骨科中心。

And yet, we -- and we haven't gone into that detail because we're not breaking out different segments of USPI. But the concept is important that we're outperforming our expectations in that acuity growth even as we continue to add centers from a -- especially when they come in large chunks like that from a more modest acuity standpoint.

然而，我們還沒有深入討論這個細節，因為我們沒有將 USPI 分成不同的部分。但這個概念很重要，即使我們繼續增加中心，我們在敏銳度成長方面的表現也超出了我們的預期——尤其是當它們從更適中的敏銳度角度大規模增加時。

So I would think about the guidance for the rest of '24, we'll get to '25. But again, I would echo the answer to the question about tailwinds in this part of the business around we see a healthy long-term growth rate in bone and joint care and ASCs.

因此，我會考慮 24 年剩餘時間的指導，我們將到達 25 年。但是，我再次重申有關該部分業務的順風問題的答案，我們看到骨骼和關節護理以及 ASC 的健康長期增長率。

And Sarah, this is Sun. Just on your second question. I would consider virtually all of the DPP amounts related to the hospital segment, just given the different patient mix and payment mix in across the two segments.

莎拉，這是 Sun。只是關於你的第二個問題。我會考慮幾乎所有與醫院部門相關的 DPP 金額，因為兩個部門的病患組合和付款組合不同。

John Ransom, Raymond James.

約翰·蘭塞姆、雷蒙·詹姆斯。

I'm going to take a shot at too, and you guys just pick your journey since that seems to be the -- what people are doing. So the first one is when we look at the expansion in the health exchanges this year, can you quantify the effect of that on USPI, if any?

我也要嘗試一下，你們只需選擇你們的旅程，因為這似乎就是人們正在做的事情。因此，第一個問題是，當我們看今年健康交易所的擴張時，您能量化這對 USPI 的影響嗎（如果有的話）？

And then secondly, I mean, Saum, you're probably tired of answering this, but are you saying that on a same-store basis in '25, we should expect total state directed payments to increase over '24? Are you not quite prepared to say that?

其次，我的意思是，Saum，你可能已經厭倦了回答這個問題，但是你是否說，在 25 年的同店基礎上，我們應該預計國家指導支付總額將比 24 年增加？你還沒準備好說那句話嗎？

Yes. We haven't made any forecast for '25 on state directed payments on a relative basis to '24. Obviously, if you compare to '23, we would expect that '25 is going to end up being higher than what it was back then. But the year-over-year, we haven't gotten to -- in the '23 to '25 step up is obviously more structural from that standpoint. Do you want to cover the [HICs]?

是的。我們還沒有對 25 年相對於 24 年的國家指導支付做出任何預測。顯然，如果與 23 年相比，我們預計 25 年的水平最終會高於當時的水平。但與去年同期相比，我們還沒有達到——從這個角度來看，23年至25年的成長顯然更具結構性。你想覆蓋[HIC]？

Yes, sure. John, on HICs, the broader trends, I think, are certainly applicable across hospitals and our ambulatory space. We haven't really quantified the USPI component of it. I do think it is probably smaller, relatively speaking, impact on ambulatory versus what we see in hospitals. And while we're talking about it, I can just remind everyone on Q3 for hospitals, we continue to see about a 58% increase in exchange volume year-over-year for Q3. So still very significant for us.

是的，當然。約翰，關於 HIC，我認為更廣泛的趨勢肯定適用於所有醫院和我們的門診空間。我們還沒有真正量化它的 USPI 成分。我確實認為，與我們在醫院看到的情況相比，它對門診的影響相對而言可能較小。在我們談論這個問題的同時，我可以提醒大家，對於醫院來說，我們繼續看到第三季的交易量比去年同期成長約 58%。所以對我們來說仍然非常重要。

It's been a benefit to the business all year absolutely.

這對全年的業務來說絕對是一個好處。

Absolutely.

絕對地。

Especially because of our contracting strategy being inclusive in the networks.

尤其是因為我們的承包策略具有包容性。

Jamie Perse, Goldman Sachs.

高盛的傑米·珀斯 (Jamie Perse)。

Can you talk a little bit about the unconsolidated ASC portfolio for a minute? Just looking for an update on where some of those facilities are at from a development and ramp perspective. how you're thinking about potential increases in ownership of those facilities going forward?

您能稍微談談未合併的 ASC 投資組合嗎？只是想從開發和提升的角度來了解這些設施的最新情況。您如何看待未來這些設施所有權的潛在成長？

Yes. No, Jamie, -- we've cut out of the bit of reporting exact numbers and other things on this as we've kind of gotten into a more stable environment after the 2022 discussion there. But yes, we continue to have buy-up opportunities. We continue to execute on buy-up opportunities within the portfolio. And it's a small, but at least on a consolidated basis, additive part of our ongoing work.

是的。不，傑米——我們已經停止了有關這方面的確切數字和其他內容的報告，因為在 2022 年的討論之後，我們已經進入了一個更穩定的環境。但是是的，我們仍然有收購機會。我們將繼續抓住投資組合內的收購機會。雖然這只是很小的一部分，但至少從綜合來看，它是我們正在進行的工作的附加部分。

Obviously, sometimes when we do that, we unlock the ability to add new business development resources for growth or other types of synergies from that perspective. But yes, it's a small, but it's not as big an opportunity as it was in the past because a lot of that stuff has been executed on.

顯然，有時當我們這樣做時，從這個角度來看，我們就能釋放出增加新業務開發資源的能力，以實現成長或其他類型的綜效。但是的，這是一個小機會，但不像過去那麼大，因為很多事情已經執行了。

We reached the end of the question-and-answer session. I'd now like to turn the call back over to management for closing comments.

問答環節已經結束。現在我想將電話轉回給管理階層，請他們發表最後評論。

That's all for today. Thank you all very much. If you have any follow-up questions, certainly feel free to reach out to me, and thank you very much for joining our call today.

今天就到這裡。非常感謝大家。如果您有任何後續問題，請隨時與我聯繫，非常感謝您今天參加我們的電話會議。

This concludes today's conference. You may disconnect your lines at this time. And we thank you for your participation.

今天的會議到此結束。現在您可以斷開您的線路。我們感謝您的參與。