環球健康 (UHS) 2023 Q2 法說會逐字稿

Good day, and thank you for standing by. Welcome to the Second Quarter 2023 Universal Health Services Earnings Conference Call. (Operator Instructions) Please be advised that today's conference is being recorded. I would now like to hand the conference over to your speaker today, Steve Filton, CFO. Please go ahead.

美好的一天，感謝您的支持。歡迎參加 2023 年第二季度全民健康服務收益電話會議。 （操作員指示）請注意，今天的會議正在錄製中。我現在想把會議交給今天的發言人、首席財務官史蒂夫·菲爾頓。請繼續。

Thank you, and good morning. Marc Miller is also joining us this morning. We welcome you to this review of Universal Health Services results for the second quarter ended June 30, 2023. During the conference call, we'll be using words such as believes, expects, anticipates, estimates and similar words that represent forecasts, projections and forward-looking statements. I recommend a careful reading of the section on Risk Factors and Forward Statements and Risk Factors in our Form 10-K year ended December 31, 2022, and our Form 10-Q for the quarter ended March 31, 2023.

謝謝你，早上好。馬克·米勒今天早上也加入我們。我們歡迎您對截至 2023 年 6 月 30 日的第二季度全民健康服務結果進行回顧。在電話會議期間，我們將使用“相信”、“預期”、“預期”、“估計”等詞語以及代表預測、預測和預測的類似詞語。前瞻性陳述。我建議仔細閱讀截至 2022 年 12 月 31 日的年度 10-K 表格以及截至 2023 年 3 月 31 日的季度的 10-Q 表格中有關風險因素和前瞻性陳述以及風險因素的部分。

We'd like to highlight just a couple of developments and business trends before opening the call up to questions. As discussed in our press release last night, the company reported net income attributable to UHS per diluted share of $2.42 for the second quarter of 2023. After adjusting for the impact of the item reflected on the supplemental schedule, as included with the press release, our adjusted net income attributable to UHS per diluted share was $2.53 for the quarter ended June 30, 2023.

在開始提問之前，我們想強調一些進展和業務趨勢。正如我們昨晚的新聞稿中所討論的，該公司公佈的 2023 年第二季度 UHS 攤薄後每股淨利潤為 2.42 美元。在對補充時間表中反映的該項目的影響進行調整後，如新聞稿所示，截至 2023 年 6 月 30 日的季度，調整後 UHS 攤薄後每股淨利潤為 2.53 美元。

Our acute hospitals experienced strong demand for their services in the second quarter with adjusted admissions increasing 7.7% over the prior year. Even though the volume growth was skewed somewhat to lower acuity procedures, overall revenue growth was still a very robust 9.7%. While overall surgical volumes were solid, increasing about 5% from the prior year quarter, there was a continuing shift from inpatient to outpatient. Meanwhile, the amount of premium pay in the second quarter was $75 million reflecting approximately 10% to 12% decline from the amount in the previous several quarters. The continued robust increase in acute volumes is the major reason that premium pay has not declined further. It's worth noting that our average hourly rate, which includes premium pay, was 4% lower than the second quarter of 2022.

我們的急症醫院第二季度的服務需求強勁，調整後的入院人數比去年同期增長了 7.7%。儘管銷量增長在一定程度上受到降低手術敏銳度的影響，但總體收入增長仍然非常強勁，達到 9.7%。雖然總體手術量穩定，比去年同期增加了約 5%，但從住院患者到門診患者的持續轉變。與此同時，第二季度的保費金額為 7500 萬美元，較前幾個季度下降約 10% 至 12%。急劇數量的持續強勁增長是保費沒有進一步下降的主要原因。值得注意的是，我們的平均時薪（包括保費）比 2022 年第二季度低 4%。

On a same-facility basis, EBITDA at our acute care hospitals increased 16% during the second quarter of 2023 as compared to the comparable prior year quarter. During the second quarter, same-facility revenues at our behavioral health hospitals increased by 7.8%, primarily driven by a 6.2% increase in revenue per adjusted patient day. The patient day growth in the quarter was greater at our acute care -- our acute behavioral hospitals versus our lower acuity residential treatment centers which tended to drive up the revenue per day beyond the already relatively robust levels we've been posting for several periods. With a similar level of revenue growth in the first quarter, same facility EBITDA for our behavioral hospitals has increased 12% in the first half of the year compared to the comparable prior year period.

在同等設施的基礎上，我們的急症護理醫院 2023 年第二季度的 EBITDA 與去年同期相比增長了 16%。第二季度，我們的行為健康醫院的相同設施收入增長了 7.8%，主要是由於調整後的患者日收入增長 6.2%。本季度我們的急症護理部門的患者日數增長更大——我們的急症行為醫院與我們的低急症住院治療中心相比，後者往往會推高每日收入，超出我們已經發布的幾個時期已經相對強勁的水平。在第一季度收入增長水平相似的情況下，我們的行為醫院上半年的相同設施 EBITDA 與去年同期相比增長了 12%。

Our cash generated from operating activities was $654 million during the first 6 months of 2023 as compared to $478 million during the same period in 2022. In the first half of 2023, we spent $337 million on capital expenditures and acquired 1.4 million of our own shares at a total cost of approximately $192 million. Since 2019, we have repurchased approximately 20% of the company's outstanding shares. As of June 30, 2023, we had $946 million of aggregate available borrowing capacity pursuant to our $1.2 billion revolving credit facility.

2023 年前 6 個月，我們的經營活動產生的現金為 6.54 億美元，而 2022 年同期為 4.78 億美元。2023 年上半年，我們的資本支出為 3.37 億美元，並收購了 140 萬股自有股票總成本約為1.92億美元。自2019年以來，我們回購了公司約20%的流通股。截至 2023 年 6 月 30 日，根據我們 12 億美元的循環信貸額度，我們擁有總計 9.46 億美元的可用借款能力。

In our acute care segment, we continue to develop additional inpatient and ambulatory care capacity. We currently have 24 operational freestanding emergency departments as well as 3 additional which are expected to be completed and opened over the next 6 months and 9 more which have been approved and are in various stages of development. Also, construction continues on our de novo acute care hospitals consisting of the 150-bed West Henderson Hospital in Las Vegas, Nevada, which is expected to open next fall; the 150-bed Alan B. Miller Medical Center in Palm Beach Gardens, Florida; and the 136 beds Cedar Hill Regional Medical Center in Washington, D.C., both of which are expected to open in 2025.

在我們的急症護理領域，我們繼續發展額外的住院和門診護理能力。我們目前擁有 24 個獨​​立運營的急診部門，另外 3 個預計將在未來 6 個月內建成並開放，另外 9 個已獲得批准並處於不同的開發階段。此外，我們的新急性護理醫院的建設仍在繼續，其中包括位於內華達州拉斯維加斯、擁有 150 個床位的 West Henderson 醫院，預計將於明年秋季開業；位於佛羅里達州棕櫚灘花園、擁有 150 個床位的艾倫 B 米勒醫療中心 (Alan B. Miller Medical Center)；位於華盛頓特區的擁有 136 個床位的 Cedar Hill 地區醫療中心預計將於 2025 年開業。

In our behavioral health segment, we recently completed and opened the 120-bed River Vista Behavioral Health Hospital in Madera, California, and we broke ground on the 96-bed Southridge Behavioral Hospital in West Michigan, a joint venture with Trinity Health Michigan, which is expected to open later next year.

在我們的行為健康領域，我們最近在加利福尼亞州馬德拉建成並開業了擁有 120 個床位的 River Vista 行為健康醫院，並在西密歇根州破土動工了擁有 96 個床位的 Southridge 行為醫院，這是與 Trinity Health 密歇根州的合資企業，預計明年晚些時候開業。

I will now turn the call over to Marc Miller, President and CEO, for some closing comments.

我現在將把電話轉給總裁兼首席執行官馬克·米勒 (Marc Miller)，請他發表一些結束語。

Thanks, Steve. We were generally pleased with our second quarter results as both of our business segments continued their transition into a post-pandemic world. As we anticipated, acute care volumes have continued their recovery trajectory, and have gradually begun to resemble the patterns we experienced before the pandemic. The comparison to last year's second quarter for our acute hospitals is the first apples-to-apples comparison of 2 low COVID volume quarters we have had since the pandemic began and the 60-basis-point year-over-year margin improvement in Q2 is a step towards a more extended margin recovery, we hope to sustain for the next several periods.

謝謝，史蒂夫。我們對第二季度的業績總體感到滿意，因為我們的兩個業務部門都在繼續向大流行後的世界過渡。正如我們預期的那樣，急症護理量繼續其恢復軌跡，並逐漸開始類似於我們在大流行之前經歷的模式。我們的急症醫院與去年第二季度的比較是自大流行開始以來我們所經歷的兩個新冠肺炎病例量較低的季度的首次同類比較，第二季度的利潤率同比提高了 60 個基點這是朝著更長期的利潤率復甦邁出的一步，我們希望在接下來的幾個時期能夠維持這一趨勢。

In our acute segment, we highlighted the upward pressure on physician expense which tended to run at a rate of about 6% of revenues pre-pandemic, but is running closer to 7.6% in 2023. Based on the generally favorable operating trends in the first half of the year, we are increasing the lower end of our 2023 EPS guidance from $9.50 a share to $9.85 a share. As we have previously disclosed, our 2023 guidance had originally assumed recognition in the fourth quarter of 2023 of $25 million of supplemental revenues from a Nevada Medicaid program. The state has dramatically reduced the funding for this program, and we now believe our fourth quarter revenue recognition will be only approximately $3 million. This reduction has informed our decision not to change the upper end of our guidance range at this time. It is worth noting that we believe a new Nevada state-directed program which we also have previously disclosed appears to still be on track for a 2024 implementation with a potentially materially favorable impact on our Nevada hospitals.

在我們的急性細分市場中，我們強調了醫生費用的上升壓力，在大流行前，醫生費用往往佔收入的 6% 左右，但到 2023 年將接近 7.6%。今年上半年，我們將 2023 年每股收益指引的下限從每股 9.50 美元上調至每股 9.85 美元。正如我們之前披露的，我們的 2023 年指導最初假設在 2023 年第四季度確認內華達州醫療補助計劃的 2500 萬美元補充收入。州政府大幅減少了對該計劃的資助，我們現在認為第四季度的收入確認將僅為約 300 萬美元。這一減少讓我們決定目前不改變指導範圍的上限。值得注意的是，我們認為我們之前也披露過的一項新的內華達州指導計劃似乎仍在按計劃於 2024 年實施，可能會對我們內華達州的醫院產生重大有利影響。

We are pleased to answer questions at this time.

我們很高興此時回答問題。

(Operator Instructions) Our first question comes from Jason Cassorla from Citi.

（操作員說明）我們的第一個問題來自花旗銀行的 Jason Cassorla。

I just wanted to ask about acute care volumes. I guess, obviously, a strong result for the first half, but wondering how you're feeling about the trajectory of those volumes in the back half of the year. And I know it's early, but do you think this creates a new base from which you grow off of for next year? Or do you think it still create kind of a set of difficult comps that you have to kind of overcome and work through in the first half of '24? Just any color or commentary around that would be helpful.

我只是想問一下急症護理量。我想，顯然，上半年的業績強勁，但想知道您對下半年這些銷量的軌蹟有何感受。我知道現在還為時尚早，但你認為這會為你明年的成長奠定一個新的基礎嗎？或者你認為它仍然會產生一系列困難的比賽，你必須在 24 年上半年克服並完成這些比賽？只要有任何顏色或評論都會有幫助。

Sure. I mean I think part of what we're experiencing in -- certainly in the first half of this year is what both, I think, providers and payers have anticipated for some time, and that is during the pandemic, there was some amount of deferral and postponement of procedures. And I think what both providers and payers have been reporting in the last quarter or 2 is that we've seen an uptick in volumes, particularly lower acuity volumes, elective and surgical procedures. Again, I think particularly skewed towards the Medicare population that probably was most prone to defer and postpone during the pandemic.

當然。我的意思是，我認為我們正在經歷的事情的一部分——當然是今年上半年，我認為提供商和付款人都已經預料到了一段時間，那就是在大流行期間，有一些推遲和推遲程序。我認為提供者和付款人在上一季度或第二季度報告的是，我們看到數量有所增加，特別是視力較低的數量、選擇性和外科手術。再說一遍，我認為特別偏向於醫療保險人群，他們在大流行期間可能最容易推遲和推遲。

It's very difficult for providers like us, and I think, quite frankly, for almost everybody, except for individual physicians to really try and precisely determine how much of current volume is an exhaustion of demand that was sort of postponed or deferred during the pandemic. I think the comment that we have made simply is that we had 10% adjusted admission growth in acute care in Q1, close to 8% in Q2. Those are really historically unprecedented numbers.

對於像我們這樣的提供者來說，坦白地說，對於幾乎每個人來說，除了個別醫生之外，要真正嘗試並精確確定目前的數量有多少是在大流行期間被推遲或推遲的需求耗盡，這是非常困難的。我認為我們所做的評論很簡單，第一季度急症護理的調整後入院增長率為 10%，第二季度接近 8%。這些確實是歷史上前所未有的數字。

So our expectation -- and again, I think Marc's comments were in Q2, for the first time, we had kind of an apples-to-apples comparison with last year in terms of low COVID volumes. We're expecting, I think, volumes to moderate in the future but also for acuity to rise and to return to sort of that mid-single-digit level of top line growth in acute care that has sort of long been the model. Whether that occurs in the next couple of quarters, whether we have a run of somewhat extended and enhanced volumes, I think is difficult for anyone to project. Obviously, it's been pretty strong for the last 6 months, early indications in July that remains that way. But we'll see. So again, I think some of our caution about guidance in the back half of the year is also informed by this idea that we're not exactly sure at what pace acute care volumes moderate, but there is some sense that they will. But generally feeling pretty good about overall acute care volumes which did suffer -- at least non-COVID volumes, which did suffer definitively during the pandemic.

所以我們的期望 - 我認為馬克的評論是在第二季度，我們第一次在新冠病毒感染量較低方面與去年進行了同類比較。我認為，我們預計未來的銷量會有所放緩，但敏銳度也會上升，並恢復到長期以來一直是急症護理領域的中個位數增長水平。無論這種情況是否會在接下來的幾個季度發生，無論我們是否會有一系列有所擴展和增強的銷量，我認為任何人都很難預測。顯然，過去 6 個月的表現相當強勁，7 月份的早期跡象仍然如此。但我們會看到。因此，我再次認為，我們對下半年指導的一些謹慎態度也源於這樣的想法：我們不確定急症護理量會以何種速度放緩，但有某種感覺，它們會放緩。但總體來說，對確實受到影響的整體急症護理量感覺良好——至少是非新冠病量，在大流行期間確實受到了影響。

Got it. Okay. And maybe just as a follow-up on the acute care physician subsidy expense. It sounds like that's coming in at an even greater pressure point than originally anticipated guidance. I guess, one, is that fair? And curious if that level of spending is at a tipping point now where maybe you need to perhaps consider greater levels of in-sourcing or other strategies to help offset and create kind of a good guy sort of set up for '24 and beyond? Any just thoughts on that would be helpful.

知道了。好的。也許只是作為急症護理醫生補貼費用的後續行動。聽起來這比最初預期的指導壓力更大。我想，一，這公平嗎？很好奇現在的支出水平是否處於臨界點，也許您需要考慮更高水平的內包或其他策略來幫助抵消並為 24 歲及以後做好準備？對此的任何想法都會有所幫助。

Yes. So we have certainly been talking about and anticipating that 2023 would be a challenging year when it came to this issue of physician subsidy expense. We talked about back in February when we gave our 2023 guidance providing like a $55 million to $60 million increase in our guidance in physician expense. The reality is the rate of increase is probably running at about twice that. I do think that this is to some degree, sort of a transitory pressure. These contract service providers who provide much of our -- especially emergency room and anesthesiology coverage are -- many of them are facing pretty significant financial stress. There have been a number of high-profile bankruptcies in that area by these contract providers.

是的。因此，我們當然一直在談論和預計，在醫生補貼費用問題上，2023 年將是充滿挑戰的一年。我們早在 2 月份就談到過，當時我們給出了 2023 年指導，將醫生費用指導增加了 5500 萬至 6000 萬美元。現實情況是增長率可能是這個數字的兩倍左右。我確實認為這在某種程度上是一種暫時的壓力。這些為我們提供大部分服務（尤其是急診室和麻醉科服務）的合同服務提供商，其中許多人面臨著相當大的財務壓力。這些合同提供商在該領域發生了多起引人注目的破產案。

And in this interim period, where we're having to replace or kind of substitute and either pay greater subsidies to our existing providers or to new providers or your question alluded to in source and hire these physicians ourselves, there's this sort of kind of onetime, hopefully, expenditure of money and dollars to make this transition. But at the end of the day, I think we have a point of view that there's X number of ER providers in the country, there's X number of anesthesiology providers in the country. And when this sort of current disruption settles out, those dollar increases like in 2024, will at a minimum level off and hopefully will actually decline. But we're not going to see this rate of increase over an extended period of time.

在這個過渡時期，我們必須更換或某種替代，或者向我們現有的提供者或新的提供者支付更多的補貼，或者你在來源中提到的問題並自己僱用這些醫生，有這種一次性的情況希望能夠花費金錢和美元來實現這一轉變。但歸根結底，我認為我們有一個觀點，即該國有 X 家急診室提供者，該國有 X 家麻醉師。噹噹前的這種混亂局面得到解決時，美元的漲幅將像 2024 年一樣，將保持在最低水平，並有望真正下降。但我們不會在很長一段時間內看到這種增長率。

Next question comes from Ben Hendrix from RBC Capital Markets.

下一個問題來自加拿大皇家銀行資本市場的本·亨德里克斯。

I was wondering if you could answer pretty much the same question on the softness in the behavioral that we saw this quarter versus first quarter. I think you had called out maybe some headwinds at some specific facilities. Just wanted to see kind of how that looks like in the back half? Is that an easy fix and what we can expect going forward?

我想知道您是否可以回答幾乎相同的問題，即我們在本季度與第一季度看到的行為疲軟程度。我認為您已經指出了某些特定設施可能遇到的一些阻力。只是想看看後半部分是什麼樣子？這是一個簡單的解決方案嗎？我們可以期待什麼？

Yes. Well, I'll go back to the point that Marc made earlier. The first quarter comparison was a bit anomalous because we were comparing kind of a low COVID volume in Q1 of 2023 with a very high volume COVID quarter in 2022. So particularly on the behavioral side, that comparison was very favorable and volumes, revenue, EBITDA growth all looked very favorable in Q1. Q2 volume growth was a little more normalized, frankly, a little softer than we anticipated. I think that our acute behavioral volumes, and I made this comment in the prepared remarks, we're actually in line with our expectations, but the volumes in our residential treatment centers were somewhat lower than expectations as we kind of dived -- or delved into those numbers.

是的。好吧，我將回到馬克之前提出的觀點。第一季度的比較有點反常，因為我們將 2023 年第一季度的新冠病毒數量較低與 2022 年的新冠病毒數量非常高進行比較。因此，特別是在行為方面，這種比較非常有利，而且數量、收入、息稅折舊攤銷前利潤 (EBITDA)第一季度的增長看起來都非常有利。坦率地說，第二季度銷量增長更加正常化，比我們預期的要溫和一些。我認為我們的急性行為量，我在準備好的發言中發表了這一評論，我們實際上符合我們的預期，但我們的住宅治療中心的量略低於預期，因為我們有點深入或深入研究到這些數字中。

It really seems like they were focused on a handful of facilities that were having specific issues, referral sources or regulatory issues that we believe will be corrected and largely resolved in the back half of the year, but didn't seem to be pervasive in any sort of company-wide or industry-wide sort of dynamic. So I think our view as we think about the behavioral business trajectory, the point that we've made for some time during the pandemic is that as COVID volumes eased, we would be able to hire more people. As we would be able to hire more people, we'd be able to generate more patient days, more volume, greater efficiencies, greater EBITDA growth.

看起來他們確實專注於少數存在具體問題、轉介來源或監管問題的設施，我們相信這些問題將在今年下半年得到糾正並基本上得到解決，但似乎並沒有在任何設施中普遍存在。一種全公司或全行業的動態。因此，我認為，當我們考慮行為業務軌跡時，我們在大流行期間一段時間以來提出的觀點是，隨著新冠疫情數量的緩解，我們將能夠僱用更多的人。由於我們將能夠僱用更多的人，我們將能夠產生更多的耐心時間、更多的產量、更高的效率和更大的 EBITDA 增長。

I think if you look at the first 6 months of the year, which, again, I made the point in my prepared remarks, EBITDA is up 12%. I think if you look at the last 4 quarters, EBITDA is up substantially. And I think that's how we're looking at the earnings power of our behavioral business. A bit of a slowdown in Q2, but I think -- we think the long-term trajectory is much more reflective of the experience we've had over the last 2 to 4 quarters.

我認為，如果你看看今年前 6 個月，我在準備好的發言中再次指出了這一點，EBITDA 增長了 12%。我認為，如果你看看過去 4 個季度，EBITDA 大幅上升。我認為這就是我們看待行為業務盈利能力的方式。第二季度略有放緩，但我認為，長期軌跡更能反映我們過去 2 到 4 個季度的經歷。

We have a question from Andrew Mok from UBS.

我們有來自瑞銀集團 (UBS) 的安德魯·莫克 (Andrew Mok) 的提問。

Same-store inpatient admissions were up about 7% in the quarter. But I think inpatient surgeries were only up about 1% or so. You mentioned lower acuity procedures, but I think those stats would imply some very strong medical growth or nonsurgical growth. Can you elaborate on the nature of the procedures you're seeing on the inpatient side?

本季度同店住院人數增長了約 7%。但我認為住院手術只增加了 1% 左右。您提到了較低的敏銳度手術，但我認為這些統計數據意味著一些非常強勁的醫療增長或非手術增長。您能否詳細說明您在住院方面看到的程序的性質？

Yes. So what I said in my prepared remarks was that overall surgical growth was up about 5% Q2 over Q2, which we view as a pretty solid outcome skewed more towards outpatient growth so outpatient procedures -- outpatient surgical procedures were up 8%, inpatient were only up 1%. But that obviously affects acuity. And again, I think in my mind, this is sort of an intuitive result. If what we're seeing in terms of the volume growth in acute care is, to some degree, a recapture of postponed and deferred procedures.

是的。因此，我在準備好的發言中所說的是，第二季度整體手術增長比第二季度增長了約 5%，我們認為這是一個相當可靠的結果，更多地偏向於門診增長，因此門診手術——門診手術增長了 8%，住院病人增長了 8%。僅上漲1%。但這顯然會影響敏銳度。我再次認為，在我看來，這是一個直觀的結果。如果我們所看到的急症護理數量增長在某種程度上是推遲和延期手術的重新出現。

It makes sense that those deferred and postponed procedures were of the lower acuity nature. Almost by definition, if people had emergency health care needs during the pandemic, those were attended to. But the things that were deferred were more elective, more discretionary procedures, both surgical and medical. And again, I think that's the dynamic you're seeing in terms of very high volumes but somewhat more muted acuity.

那些推遲和延期的手術具有較低的敏銳度，這是有道理的。幾乎根據定義，如果人們在大流行期間有緊急醫療保健需求，就會得到滿足。但被推遲的事情是更具選擇性、更具自由裁量權的手術，包括外科手術和內科手術。再說一遍，我認為這就是你所看到的動態，成交量非常大，但敏銳度卻有些減弱。

Got it. And just a quick follow-up. How is the Reno Hospital tracking against expectations. Can you help quantify the contribution that, that hospital had on same-store admissions growth in the quarter?

知道了。只是快速跟進。里諾醫院的進展情況與預期相符嗎？您能否幫助量化該醫院對本季度同店入院人數增長的貢獻？

Yes. I don't have those exact admission numbers for the Reno Hospital in front of me, but I'll say that -- what we have said was included in our 2023 guidance was about a $25 million or $30 million turnaround at the Reno Hospital. I think we're tracking -- I think we anticipated that, that would be a little back-end loaded, and I think that's right.

是的。我面前沒有里諾醫院的確切入院人數，但我要說的是，我們所說的 2023 年指導中包含的內容是里諾醫院的扭虧為盈約為 2500 萬美元或 3000 萬美元。我認為我們正在跟踪——我認為我們預料到了這一點，這將有一點後端負載，我認為這是正確的。

I think we probably had about a $4 million or $5 million improvement in Q2. But I think we're generally tracking for that level of improvement for the full year, and that's our expectation. My sense is the Reno Hospital is not large enough to have had a significant impact on admissions one way or the other in the quarter.

我認為第二季度我們可能獲得了大約 400 萬或 500 萬美元的改進。但我認為我們總體上會跟踪全年的改進水平，這就是我們的期望。我的感覺是，里諾醫院規模不夠大，不足以對本季度的入院人數產生重大影響。

Our next question comes from Joshua Raskin from Nephron Research.

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

Just the first question, getting back to the behavioral health margins. I think in the past, you've suggested, and I think you just alluded to this, Steve, that there just weren't enough clinicians to hire and that sort of slowed your volumes. Are you now able to find these clinicians? If so, where are they coming from? And are different categories, maybe nurses versus MD is performing different roles. I'm just curious how you're feeling that capacity.

只是第一個問題，回到行為健康邊際。我想在過去，你已經建議過，而且我想你只是提到了這一點，史蒂夫，就是沒有足夠的臨床醫生來僱用，這在某種程度上減緩了你的數量。您現在能找到這些臨床醫生嗎？如果有，它們來自哪裡？而且是不同的類別，也許護士和醫學博士扮演著不同的角色。我只是好奇你對這種能力有何感受。

Yes. I mean, so what I think we have said pretty consistently throughout the pandemic is that the pandemic itself -- and I should start by making the point that prior to the pandemic, in late 2019, early 2020, I think we would have described, and I think most of our provider colleagues would have described the labor market. It's pretty tight back then. The overall unemployment rate in the country was, I think, pretty close to full employment, clinical employment, particularly nursing employment was very tight. .

是的。我的意思是，所以我認為我們在整個大流行期間一直在說的是大流行本身 - 我應該首先指出，在大流行之前，即 2019 年末、2020 年初，我認為我們會描述，我認為我們的大多數供應商同事都會描述勞動力市場。那時候還挺緊的。我認為，該國的總體失業率非常接近充分就業，臨床就業，特別是護理就業非常緊張。 。

The pandemic then really exacerbates that tightness, particularly for subacute providers like behavioral providers because we started to lose a great many nurses, especially nurses to these high-level premium pay opportunities they were having working in acute care hospitals and COVID units or ERs or ICUs, et cetera. And the argument we made all along was that as COVID volumes declined, those opportunities for these extraordinary pay increases would decline and nurses would return to their we'll sort of call it home base and employment. And I think that's what we've been seeing I'm going to say, for the last 12 or 15 months, I'm going to say at least back to the spring -- the early spring of 2022. And we're seeing that.

這種流行病確實加劇了這種緊張，特別是對於像行為提供者這樣的亞急性提供者來說，因為我們開始失去很多護士，特別是那些在急症護理醫院和新冠病房、急診室或重症監護室工作的護士，他們擁有這些高水平的高薪機會。等等。我們一直提出的論點是，隨著新冠病毒感染人數的下降，這些超常加薪的機會將會減少，護士將回到他們的基地和就業崗位。我認為這就是我們在過去 12 或 15 個月裡所看到的情況，我要說的是，至少回到了春天——2022 年初春。我們看到那。

Now what we're seeing is an increase in base wage rates in order for us to get those folks back. So I think wage inflation and behavioral or average hourly rate increase in Q2 over the prior year is more like 4.5%, 5%, which is certainly higher than it was running in the pandemic. And again, you see some of that in our salary, overall salary increases. But at the end of the day, and this is the point that I was trying to make before, I think what we've demonstrated, especially over the last 3 quarters, and to a lesser degree, in Q2 of this year is, as we're able to hire more people, we're able to generate more volumes and as a consequence, EBITDA growth, margin improvement, et cetera.

現在我們看到的是基本工資率的提高，以便我們讓這些人回來。因此，我認為第二季度的工資通脹和行為或平均小時工資較上年增長更像是 4.5%、5%，這肯定高於大流行期間的水平。再說一次，你會在我們的薪水、整體薪水增長中看到其中的一些內容。但歸根結底，這就是我之前試圖提出的觀點，我認為我們所展示的，特別是在過去三個季度中，以及在較小程度上，在今年第二季度中，我們能夠僱用更多的人，我們能夠產生更多的銷量，從而實現 EBITDA 增長、利潤率提高等等。

It's not a directly-it's not a ratable increase every single quarter. But -- and again, there's some element of timing here as we hire new people, they have to be trained and oriented and that causes some level of inefficiency. But over time, I think we have the view that we're going to continue to be able to hire more people in behavioral and admit more patients and that's going to lead to a long-term growth trajectory in that business.

這不是直接的——也不是每個季度都會有可比的增長。但是——再說一次，當我們僱用新人時，這裡有一些時機因素，他們必須接受培訓和指導，這會導致一定程度的低效率。但隨著時間的推移，我認為我們將繼續能夠僱用更多的行為學人員並接納更多的患者，這將導致該業務的長期增長軌跡。

Got you. Got you. And then just one more on United spoke about a large increase in the incidence of mental health utilization, just more people seeking services. Do you think that translates to more inpatient care? Or is that a level of acuity that's been more steady on the inpatient side and maybe that's more lower acuity?

明白你了。明白你了。然後，聯合航空的另一則新聞談到心理健康利用的發生率大幅增加，只是有更多的人尋求服務。您認為這會帶來更多的住院治療嗎？或者說住院患者的視力水平比較穩定，也許視力較低？

Yes. My recollection from reading the United transcript was that they specifically talked about that increase being skewed to outpatient procedures. And obviously, I think outpatient is a more highly competitive sort of market for behavioral, there's a lot more competitors. I think our view is over the long term, the more people who are getting care and getting appropriate assessments, et cetera, is good for our business, which tends to have a much broader continuum of care that includes more intensive outpatient and partial hospitalization and all sorts of inpatient care across many diagnoses.

是的。我在讀美聯航的文字記錄時記得，他們特別談到了門診手術的增加。顯然，我認為門診是一個競爭更加激烈的行為市場，有更多的競爭對手。我認為我們的觀點是，從長遠來看，獲得護理和適當評估等的人越多，對我們的業務有利，我們的業務往往有更廣泛的連續護理，包括更密集的門診和部分住院治療以及涵蓋多種診斷的各種住院護理。

So I think we have a view that while we didn't necessarily experience that same growth in outpatient that United referred to specifically, I think, in their first -- second quarter call, that ultimately down the road, we're likely to benefit from more and more people getting the appropriate level of behavioral care and assessment.

因此，我認為我們認為，雖然我們不一定會經歷曼聯在第一季度和第二季度電話會議中特別提到的門診量增長，但最終我們可能會受益越來越多的人獲得適當水平的行為護理和評估。

Our next question comes from Whit Mayo from Leerink Partners.

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

Steve, I appreciate the comments on Nevada and the supplemental Medicaid program changes. Any way to potentially size how you guys are thinking about the potential contribution of that in 2024? I know there's still some moving pieces and approvals that need to happen.

史蒂夫，我感謝您對內華達州和補充醫療補助計劃變更的評論。有什麼方法可以衡量你們如何看待 2024 年的潛在貢獻嗎？我知道還需要一些進展和批准。

Yes. So we're waiting with for the state to resume more specific guidance about how their specific methodology is going to work, et cetera. But based on our broad understanding of how this program is going to work as I think Marc commented in his prepared remarks, our expectation is that this could have a materially favorable benefit on our Nevada hospitals. But we're anxiously waiting for the state to issue more specifics surrounding the calculations and the methodology and the size of the pool, et cetera, which we think could be forthcoming, I'm going to sort of say in the near intermediate term. But certainly, we think there'll be a lot more clarity by the end of the year.

是的。因此，我們正在等待國家恢復關於其具體方法如何運作等更具體的指導。但根據我們對這個計劃將如何運作的廣泛理解，正如我認為馬克在他準備好的講話中評論的那樣，我們的期望是，這可能會給我們內華達州的醫院帶來物質上的有利好處。但我們正在焦急地等待國家發布有關計算、方法和資金池規模等的更多細節，我們認為這些細節可能會在近期內發布。但當然，我們認為到今年年底，情況將會更加清晰。

Yes. Okay. No, that's helpful. We've gotten some questions around the Cerner Oracle EMR investments you guys are making. None of this is new. But just maybe remind us the income statement, CapEx impact, how many hospitals you're thinking about converting? I can't imagine that's all of your facilities, just time line and any review of that initiative?

是的。好的。不，這很有幫助。我們收到了一些有關你們正在進行的 Cerner Oracle EMR 投資的問題。這些都不是什麼新鮮事。但也許提醒我們損益表、資本支出影響、您正在考慮轉換多少家醫院？我無法想像這就是您的所有設施，只有時間表和對該計劃的任何審查？

Sure. So as you said, this is not necessarily really new news. We originally committed to a behavioral EMR implementation with Cerner. Going back a couple of years, and after Cerner's acquisition by Oracle, Oracle wanted to do this press release, which is fine. But to be clear, I mean, it's not new. We've already implemented a handful of facilities in 2022. We'll implement another round of facilities in 2023. If you read the press release, it doesn't refer to the number of facilities. I think when at least one of the news media outlets picked up the story they sort of combine the fact that we were making this announcement with the fact that we've got 200 behavioral facilities here in the U.S. and said that we were committed to implement 200 facilities.

當然。正如你所說，這不一定是新消息。我們最初致力於與 Cerner 一起實施行為 EMR。回想幾年前，在 Cerner 被 Oracle 收購之後，Oracle 想要發布這篇新聞稿，這很好。但要明確的是，我的意思是，這並不新鮮。我們已經在 2022 年實施了一些設施。我們將在 2023 年實施另一輪設施。如果您閱讀新聞稿，它並不是指設施的數量。我認為，當至少一家新聞媒體報導了這個故事時，他們將我們發布此公告的事實與我們在美國擁有 200 個行為設施的事實結合起來，並表示我們致力於實施200個設施。

As your question alludes to, we certainly have not yet committed to that. we have smaller residential facilities that may not be appropriate for an investment of this scale, et cetera. So I think the point -- I mean, I think that we will spend significantly less on behavioral EMR than we did on the acute care EMR, I think, around $220 million, $230 million a number of years ago on the implementation of an acute care EMR. I think we'll spend substantially less on behavioral and they'll be spread out over, I think, a 5- or 6-year period.

正如你的問題所暗示的那樣，我們當然還沒有對此做出承諾。我們有較小的住宅設施，可能不適合這種規模的投資，等等。所以我認為這一點 - 我的意思是，我認為我們在行為 EMR 上的支出將比在急性護理 EMR 上的支出少得多，我認為，幾年前用於實施急性護理 EMR 的支出約為 2.2 億美元、2.3 億美元護理電子病歷。我認為我們在行為方面的支出將大大減少，並且我認為它們將分散在 5 或 6 年的時期內。

So I don't think that the individual impact of the investment is going to have a significant impact. The other piece is we had an expectation that there are operating efficiencies that we'll gain and garner from the implementation. So a significant chunk of that investment should be offset with operating efficiencies.

因此，我認為投資的個人影響不會產生重大影響。另一方面，我們期望我們將從實施中獲得運營效率。因此，該投資的很大一部分應該通過運營效率來抵消。

We have a question from A.J. Rice from Credit Suisse.

我們有 A.J. 的問題。瑞士信貸的大米。

I know you've gotten some good rate increases on the behavioral side the last year or so is -- I know a lot of states reset their rates midyear. I also know you've got ongoing discussions on the commercial side. Medicare, we can track that easier. But any update on thinking about where rates settle out back half of the year into next year for commercial and Medicaid in the behavioral side?

我知道去年左右在行為方面你已經得到了一些很好的加息——我知道很多州在年中重置了他們的費率。我還知道你們正在就商業方面進行持續的討論。醫療保險，我們可以更輕鬆地追踪。但是，對於行為方面的商業和醫療補助費率從今年下半年到明年的穩定情況，有什麼最新的思考嗎？

Yes. I mean, A.J., I think our comments on rate increases and behavioral have been pretty consistent. They definitely -- historically, revenue per day in the behavioral division has generally increased sort of 2% or 3% a year, pretty consistently pre-pandemic. During the pandemic, we saw those numbers rise to something much closer to 5% to 6%. And then I think we've generally discussed that, and we think the main reason for that is we've been able to leverage the fact that there is capacity constraints in the industry as we've already talked about on this call because of -- labor capacity especially.

是的。我的意思是，A.J.，我認為我們對加息和行為的評論非常一致。從歷史上看，行為部門的每日收入通常每年增長 2% 或 3%，在大流行前幾乎一直如此。在大流行期間，我們看到這些數字上升至接近 5% 至 6%。然後我認為我們已經普遍討論了這一點，我們認為主要原因是我們能夠利用行業中存在產能限制的事實，正如我們在這次電話會議中已經討論過的那樣，因為 - - 尤其是勞動力能力。

And we've been going to our lowest payers and either demanding increases from them or canceling those contracts that we view to be inadequate and simply admitting patients whose insurance will pay us more, again, in an environment where we can only treat a limited number of patients, we can be more selective about who we treat and the fairness of what we think we're being paid.

我們一直向支付最低的人尋求幫助，要么要求他們增加費用，要么取消那些我們認為不充分的合同，只是接納那些保險會支付更多費用的患者，同樣，在我們只能治療有限數量的環境中對於患者，我們可以更有選擇性地對待我們的治療對像以及我們認為我們得到的報酬的公平性。

What we have said is we think that as we're able to admit more patients, our ability to leverage that diminishes a little bit and maybe that revenue per day increase that had been running 5% to 6% moderates more to 4% to 5%. We were again a little over 6% in the quarter, although that, I think, is a function not only of the rate increases we're getting but also of the mix of acute versus residential patients, as I mentioned before.

我們所說的是，我們認為，隨著我們能夠接納更多患者，我們的槓桿能力會有所減弱，也許每天的收入增長從 5% 到 6% 會放緩至 4% 到 5% %。本季度我們的增長率再次略高於 6%，儘管我認為這不僅與我們的增長率有關，而且與急性患者與住院患者的混合有關，正如我之前提到的。

But I think generally, our price -- the pricing environment in behavioral remains strong. We remain aggressive that we've terminated or issued notice of termination in a great many markets to a great many payers. We're pursuing this strategy pretty aggressively and feel like there's runway to do so for the foreseeable future.

但我認為總的來說，我們的價格——行為定價環境仍然強勁。我們仍然積極進取，我們已在許多市場向許多付款人終止或發出終止通知。我們正在非常積極地推行這一戰略，並且感覺在可預見的未來仍有實現這一戰略的空間。

Okay. I know you talked about the new facility in Vegas and the trajectory there. But maybe stepping back, I know you've got concentrated portfolios in the acute side in Vegas and Southern California and D.C. and Southwest Texas, any dispersion? Obviously, you had good overall volume growth. Was there much of a difference in the performance in those major geographic markets this quarter?

好的。我知道您談到了維加斯的新設施以及那裡的發展軌跡。但也許退一步說，我知道您的投資組合集中在拉斯維加斯、南加州、華盛頓特區和德克薩斯州西南部的急需區域，有分散的情況嗎？顯然，你們的整體銷量增長良好。本季度這些主要地區市場的表現是否存在很大差異？

So I think like most of our -- or several of our public peers, HCA and Tenet, I think most notably have commented in the last year or so that their facilities in Texas and Florida have been recovering at a more rapid rate than in other geographies. I think as those states have emerged from the pandemic, more around the economies in those states have emerged on the pandemic more rapidly. I think honestly, that has been sort of a bit of a negative comparison for us. Again, over the last year or so because we've got less of a relative footprint in Texas and Florida and more in Nevada and California than our peers.

因此，我認為，就像我們的大多數或我們的幾個公共同行一樣，HCA 和 Tenet 在去年左右發表了評論，他們在德克薩斯州和佛羅里達州的設施恢復速度比其他地區更快地理。我認為，隨著這些州擺脫了大流行的影響，這些州的更多經濟體也更快地擺脫了大流行的影響。老實說，我認為這對我們來說有點負面的比較。同樣，在過去一年左右的時間裡，我們在德克薩斯州和佛羅里達州的相對足跡比同行少，而在內華達州和加利福尼亞州的足跡比同行多。

But I think what we're seeing now is the recovery in those geographies is starting to pick up pace, et cetera. I think our performance in Nevada was particularly improved in the quarter. And obviously, that's always a significant piece of good news for us. I will say that to have the sort of acute care performance we had, in particular, the top line and EBITDA growth of 16% that's got to be pretty broad-based. It really can't be specific to one single market, and I don't think it was. But again, the encouraging, I think, element for us specifically was the improvement in our Nevada results in the quarter.

但我認為我們現在看到的是這些地區的複蘇開始加快步伐，等等。我認為本季度我們在內華達州的業績尤其有所改善。顯然，這對我們來說始終是一個重要的好消息。我想說的是，要實現我們的急症護理業績，尤其是 16% 的營收和 EBITDA 增長，基礎必須相當廣泛。它確實不能只針對某一單一市場，我也不認為是這樣。但我認為，對我們來說特別令人鼓舞的因素是本季度內華達州業績的改善。

We have a question from Jamie Perse from Goldman Sachs.

我們有來自高盛 (Goldman Sachs) 的傑米·珀斯 (Jamie Perse) 的提問。

I just wanted to go back to the other operating expenses within acute for a second. You spoke about some of the bankruptcies for vendors in the space. Are there specific sort of onetime disruption costs in the $590 million you realized this quarter? I'm just trying to understand where we're going from here, if that's the right new baseline? Or if you can take cost out at some point? Just any more color on the near term and how to model that line item?

我只想暫時回顧一下其他運營費用。您談到了該領域供應商的一些破產情況。您本季度實現的 5.9 億美元中是否存在特定類型的一次性中斷成本？我只是想了解我們接下來要走向何方，這是否是正確的新基線？或者您是否可以在某個時候扣除成本？近期是否還有更多顏色以及如何對該訂單項進行建模？

Yes. Look, I made the point earlier, Jamie, that we anticipated a significant increase in those physician subsidy expenses in our 2023 guidance. But in the first 6 months, they're tracking twice the rate that we anticipated. But I also tried to make the point that I think we believe that these really dramatic increases are a function of this current disruption. We've got providers who are telling us one or two things.

是的。傑米，我之前說過，我們預計 2023 年指南中的醫生補貼費用將大幅增加。但在前 6 個月，他們的跟踪速度是我們預期的兩倍。但我也試圖指出，我認為我們相信這些真正戲劇性的增長是當前這種破壞的結果。我們的提供商告訴我們一兩件事。

One is that they just can't continue. They've declared bankruptcy, and they can't continue to provide the contract services that we're contracted for. And we're having to replace them generally at a higher cost, whether we're contracting out to somebody else or hiring these folks in. And again, there's the sort of transition costs that I think are largely onetime in nature.

一是他們無法繼續下去。他們已經宣布破產，無法繼續提供我們簽約的合同服務。而且我們通常必須以更高的成本替換它們，無論我們是外包給其他人還是僱用這些人。而且，我認為這種過渡成本基本上是一次性的。

But I think we're going to continue to experience these for the next quarter or so. I think, we have a general view that by the time we get to 2024 -- however, this has settled out either -- and I'm not sure there's a single answer. But I think, either a lot of these providers, these ER and anesthesiology physicians will be employed by hospitals and by us or they'll be employed by more local and regional providers who are more healthy financially, et cetera. But we're going to see a leveling off of this expense.

但我認為我們將在下個季度左右繼續經歷這些。我認為，我們普遍認為，到 2024 年時——然而，這已經解決了——而且我不確定是否有一個單一的答案。但我認為，要么很多這些提供者，這些急診室和麻醉科醫生將受僱於醫院和我們，要么他們將受僱於更多財務狀況更健康的本地和區域提供者，等等。但我們將會看到這項支出趨於平穩。

I don't know that we're able to predict exactly how you should model that in the future. And again, I think in my mind, the positive view of this in the quarter is acute care EBITDA is 16% higher than it was last year's Q2, despite the fact that we've got this significantly increased burden of physician expense. We feel like when that levels off next year, that's going to provide a boost to our earnings power.

我不知道我們是否能夠準確預測您將來應該如何建模。再說一次，我認為，在我看來，本季度的積極看法是急症護理 EBITDA 比去年第二季度高出 16%，儘管我們的醫生費用負擔顯著增加。我們認為，當明年這種情況趨於平穩時，這將提振我們的盈利能力。

Okay. And you and other hospitals have always talked about a strong margin profile on surgery. Just given the tailwinds that seem to be in the surgical space at this point, can you give us any color on how to think about profit margins in your surgical business or profit contribution on average from surgeries?

好的。你們和其他醫院一直在談論手術的強勁利潤率。考慮到目前外科領域似乎存在的順風車，您能否告訴我們如何考慮外科業務的利潤率或手術的平均利潤貢獻？

Yes. I mean, I think if you think about if -- however you want to find our long-term acute care margins in the upper teens, I'm going to call it 17%, something like that. But I think, surgical margins tend to be probably 5 to 10 basis points above that and medical margins tend to be 5 to 10 basis points below that. Obviously, there's a lot of difference depending on the specific procedure, the length of stay, the demographics of the patient base, et cetera. But historically, surgical margins have been measurably higher than medical margins.

是的。我的意思是，我想如果你想——無論如何你想找到我們在十幾歲以上的長期急性護理利潤率，我會把它稱為 17%，類似的東西。但我認為，手術利潤率往往比該利潤率高 5 到 10 個基點，而醫療利潤率往往比該利潤率低 5 到 10 個基點。顯然，根據具體手術、住院時間、患者群體的人口統計等因素，存在很大差異。但從歷史上看，手術利潤率明顯高於醫療利潤率。

Our next question will come from Scott Fidel from Stephens.

我們的下一個問題將來自斯蒂芬斯的斯科特·菲德爾。

A couple of recent developments or proposals on the policy side, I would be interested to get your initial thoughts on -- the first was the CMS proposal that came out around the intensive outpatient benefit for behavioral in Medicare. And then just yesterday, I know it just came out, so don't expect too detailed commentary, but the Biden administration did also just come out with -- with an updated proposal really sort of focused on health plans around mental health parity and sort of enforcing that around in-network for behavioral. So just interested on both those proposals, if you have any initial thoughts on potential risks and opportunities there.

政策方面最近的一些進展或建議，我有興趣了解您的初步想法 - 第一個是 CMS 提案，該提案圍繞醫療保險行為的強化門診福利而提出。就在昨天，我知道它剛剛發布，所以不要期待太詳細的評論，但拜登政府也剛剛發布了——更新後的提案確實側重於圍繞心理健康平等和分類的健康計劃圍繞網絡內的行為強制執行這一點。因此，如果您對其中的潛在風險和機遇有任何初步想法，請對這兩個提案感興趣。

Yes. So I'll tackle the parity one, which I know is the more recent one, Scott, first. As you pointed out, I mean, I think the Biden administration announced yesterday that they were going to issue new rules on mental health parity, which they did this morning, and I appreciate your acknowledgment that we have not had a chance to review those. I think the broad context here is mental health parity legislation originally passed almost 15 years ago.

是的。因此，我將首先解決奇偶校驗問題，我知道這是最近的一個問題，斯科特。正如你所指出的，我的意思是，我認為拜登政府昨天宣布，他們將發布有關心理健康平等的新規則，他們今天早上就這樣做了，我感謝你承認我們沒有機會審查這些規則。我認為這裡的廣泛背景是大約 15 年前最初通過的心理健康平等立法。

But I think, the industry has always been frustrated that the amount of adherence and an enforcement on the part of the government has never at least been as fulsome as the industry would have liked. And without reading the specific regulations or having a chance to read the specific regulations, I think the one positive that we take away is that the current administration seems focused on the fact that there needs to be better enforcement, there need -- the mental health parity legislation originally was, I think, viewed very positively for the industry. And I do think it had a positive impact, but I think it should be more positive.

但我認為，業界一直感到沮喪的是，政府方面的遵守和執行力度從來沒有像業界所希望的那樣充分。在沒有閱讀具體規定或有機會閱讀具體規定的情況下，我認為我們得到的一個積極的結果是，現任政府似乎關注這樣一個事實，即需要更好的執法，需要——心理健康我認為，平價立法最初對該行業的看法非常積極。我確實認為它產生了積極的影響，但我認為應該更積極。

And I think we would argue that there have been plans and payers that have sort of tried to dodge the intent of the legislation and we believe that any effort on the part of this administration to more aggressively enforce those parity laws is welcome.

我認為我們會爭辯說，有些計劃和付款人試圖迴避立法的意圖，我們相信本屆政府為更積極地執行這些平等法所做的任何努力都是值得歡迎的。

The intensive outpatient regulations, I'll sort of make repeat the same comments I was making just about United's commercial comments or commercial utilization comments before -- I think that any new developments that allow people or encourage people to get more access to in terms of outpatient or behavioral care in general are generally going to be positive for us. We have a lot of intensive outpatient offerings. But I think more than that, I think we had this complete continuum of care from very low acute outpatients or very high acute inpatients, that the more people who are given access to care and behavioral diagnosis and assessment. I think that's generally good news for us.

密集的門診規定，我會重複我之前對聯合航空的商業評論或商業利用評論所做的相同評論 - 我認為任何允許人們或鼓勵人們獲得更多機會的新發展一般來說，門診或行為護理通常會對我們產生積極的影響。我們有很多密集門診服務。但我認為更重要的是，我認為我們從非常低的急性門診患者或非常高的急性住院患者那裡獲得了完整的連續護理，越多的人獲得護理和行為診斷和評估。我認為這對我們來說總體上是個好消息。

So I would say, we view both of these developments as a positive. I think, we view them consistent with, I think, general legislative and administrative sort of favorability to the behavioral business at both the federal and state level, difficult to quantify the benefit for either of those in any sort of precise way.

所以我想說，我們認為這兩項進展都是積極的。我認為，我們認為它們與聯邦和州層面對行為企業的一般立法和行政優惠是一致的，很難以任何精確的方式量化其中任何一個的利益。

Got it. And then just one quick follow-up. Just on the Medicare volume sort of normalization that we've been seeing. Anyway, can you sort of tease out just in the second quarter, how I guess that's sort of skewed between outpatient and inpatient? Obviously, we know that it's felt seem to be sort of heavily driven by outpatient. But I'm interested whether you saw a pickup in the inpatient side skew on the Medicare volumes as well.

知道了。然後只是一個快速跟進。就我們所看到的醫療保險規模的正常化而言。不管怎樣，你能在第二季度梳理一下，我猜門診和住院之間的情況是如何傾斜的嗎？顯然，我們知道這似乎很大程度上是由門診患者驅動的。但我感興趣的是，您是否也看到醫療保險數量的住院側偏斜有所回升。

Yes. I mean, so we saw, as we said, adjusted admissions increased by almost 8% in the quarter. Some of that is certainly driven by the outpatient activity. But obviously, pure admission growth was also pretty strong. Again, I just feel like what you're seeing is, it is a bit skewed towards the lower acuity procedures.

是的。我的意思是，正如我們所說，本季度調整後的招生人數增加了近 8%。其中一些肯定是由門診活動推動的。但顯然，純入場人數增長也相當強勁。再說一次，我只是覺得你所看到的是，它有點偏向於較低的敏銳度程序。

And again, not by a tremendous amount. I mean, we saw overall revenue per adjusted admission on the acute side increased by 2% or so in the quarter. I think normally, we would expect that number to be more in the 2% to 4% range. So it's kind of on the low end. But there's a little bit more of that skew to -- I think, it's not so much -- I mean, it is clearly an inpatient and outpatient issue, but I think it's more of an issue of skewing more towards those elective and deferred procedures that were postponed whether they were in or outpatient during the pandemic and are now being realized in greater numbers.

再說一次，數量並不是很大。我的意思是，我們看到本季度調整後的入場總收入增加了 2% 左右。我認為通常情況下，我們預計這個數字會在 2% 到 4% 的範圍內。所以它有點低端。但還有一點偏向——我認為，沒有那麼多——我的意思是，這顯然是一個住院和門診問題，但我認為這更多的是一個更多偏向那些選擇性和延期程序的問題在大流行期間，無論他們是住院還是門診，這些計劃都被推遲，但現在正在大量實現。

Our next question comes from Justin Lake with Wolfe Research.

我們的下一個問題來自沃爾夫研究中心的賈斯汀·萊克。

First question, I wanted to ask about what you're seeing from the payers. I know you already got asked about pricing. But given Medicaid payers are heading into redeterminations, Medicare Advantage payers are talking about higher utilization. Steve, are you seeing any early kind of signs of increased medical management claims, denial, et cetera, the typical stuff that managed care will do when their costs are or might be a little bit higher?

第一個問題，我想問一下您從付款人那裡看到的情況。我知道您已經被問及定價問題。但鑑於醫療補助付款人正在重新確定，醫療保險優惠付款人正在談論更高的利用率。史蒂夫，您是否看到醫療管理索賠、否認等增加的任何早期跡象，這些是管理式醫療在成本較高或可能較高時會做的典型事情？

Yes. So two things or two comments that you made, Justin. I mean, one is, we're not seeing, I think, at least a measurable impact that we can identify from Medicaid redetermination so far. I do think again, we -- Marc commented on the rationale for not raising the upper end of our guidance, he commented on the Nevada supplemental payment. I do think that's a big piece of it.

是的。賈斯汀，你發表了兩件事或兩條評論。我的意思是，其中之一是，我認為，到目前為止，我們至少沒有看到我們可以從醫療補助重新確定中確定的可衡量的影響。我確實再次想到，我們——馬克評論了不提高我們指導上限的理由，他評論了內華達州的補充付款。我確實認為這是其中很大一部分。

But I think we also have a view that there may yet be an impact from Medicaid redeterminations in the back half of the year in both of the businesses that we have not yet seen. So we're paying very close attention to that, and that's a focus.

但我認為我們也認為下半年醫療補助重新確定可能會對這兩項業務產生影響，但我們尚未看到。所以我們非常密切地關注這一點，這是一個焦點。

But I think your other comment is also well taken, and that is with a lot of the payers reporting an increase in their own medical laws utilization, we have an expectation that we're going to see more aggressive behavior on their part to whatever it may be limit length to stay on the behavioral side or challenge more inpatient versus observation, classification on the acute side. I can't say that we can say definitively that we've seen that change in a measurable way just yet.

但我認為你的其他評論也得到了很好的接受，那就是，隨著許多付款人報告他們自己的醫療法利用率有所增加，我們預計我們將看到他們在任何方面採取更激進的行為可能會限制行為方面的停留時間或挑戰更多住院患者與觀察、急性方面的分類。我不能說我們可以明確地說我們已經看到了可衡量的變化。

I think it sometimes takes a quarter or 2 for that information to sort of play out. But I will tell you that we're very prepared for and very focused on it. I think in all sorts of ways, I think we're trying to change our contracts so that these issues are more defined, that are in upfront in the contract, but also in the way that we provide billing information and we go through the appeal process. So all those things are a significant focus of ours. But I think you are suggesting that managed care payers are likely to become more aggressive in their utilization review procedures, is something we're very sensitive to and prepared for.

我認為有時需要一兩個季度這些信息才能發揮作用。但我會告訴你，我們已經做好了充分準備，也非常專注。我認為以各種方式，我認為我們正在嘗試改變我們的合同，以便這些問題更加明確，這些問題都在合同的前期，而且還以我們提供賬單信息和處理上訴的方式過程。因此，所有這些事情都是我們的重點。但我認為您的意思是，管理式醫療付款人可能會在使用審查程序中變得更加積極，這是我們非常敏感並做好準備的事情。

I appreciate that. Maybe you can expand on your commentary around redeterminations. I know, a lot of us are uncertain how this plays out. But one kind of line of thinking is that a bunch of people are going to be kicked off Medicaid, and a lot of them could end up on the exchanges or on private employer health plans, which pay a lot better, right, especially on the acute side, but even on the behavioral side.

我很感激。也許您可以圍繞重新決定展開您的評論。我知道，我們很多人都不確定事情會如何發展。但一種想法是，一群人將被踢出醫療補助，其中很多人最終可能會參加交易所或私人雇主健康計劃，這些計劃的報酬要好得多，對吧，尤其是在尖銳的一面，甚至是行為方面。

So how do you think about that vis-a-vis? Do you just think that, is your concern that a lot of folks are going to be unfortunately remove from the roles and not pick up other coverage? Is it your market specific to you, given your geographic exposure? Or do you think that's just broad-based? And what drives that?

那麼您對此有何看法？您是否只是認為，您是否擔心很多人會不幸地從這些角色中刪除並且無法獲得其他報導？考慮到您的地理分佈，這是您特定的市場嗎？或者您認為這只是廣泛的基礎？是什麼推動了這一點？

Yes. So I think that we generally concur, as your question sort of alluded to with the sort of broad way that a number of analysts both, I'm going to say, this passionate analysts like CMS and the Urban Institute, et cetera, when they looked at the potential impact of redeterminations and then the number of sell-side folks have done, pretty exhaustive studies. And I think, they all conclude largely the way you framed your question that ultimately, there will be a sufficient number of people who are redetermined off the Medicaid roles but who can requalify on better paying commercial products, commercial exchange products that the net impact to providers will be a positive one.

是的。因此，我認為我們總體上同意，正如您的問題所暗示的那樣，許多分析師，我要說的是，像 CMS 和城市研究所等充滿熱情的分析師，當他們研究了重新確定的潛在影響，然後賣方人員的數量進行了相當詳盡的研究。我認為，他們的結論很大程度上與您提出問題的方式相同，即最終將有足夠多的人被重新確定為醫療補助角色，但他們可以重新獲得支付更高報酬的商業產品、商業交換產品的資格，這些產品的淨影響是供應商將是一個積極的供應商。

I think, our sort of skepticism or concern or caution is more short term or timing related in nature and that is as we go through the process and people get redetermined off, how quickly can they requalify for commercial products, et cetera. And again, I just don't think we've had enough time to really measure whether there could be sort of a short-term bump or a drain on this.

我認為，我們的懷疑、擔憂或謹慎本質上是短期的或與時間相關的，也就是說，當我們經歷這個過程時，人們會重新確定他們能夠以多快的速度重新獲得商業產品的資格，等等。再說一次，我認為我們沒有足夠的時間來真正衡量是否會出現短期的衝擊或消耗。

But I think in the long run, we think we probably come out at least whole, if not somewhat ahead. The good news from my perspective is based on the redetermination data that I've seen, while there have been a lot of people redetermined off, a lot of those redeterminations a good chunk of them are sort of more for administrative reasons. Their paperwork is not up to date, their address is not up date, whatever it may be. And so it feels like those people will be able to get back on the Medicaid roles quickly. So it feels like maybe the impact in the long run is not going to be as significant as we might have thought. But again, our point of view is maybe some short-term uncertainty over the long term, I don't think we think this is really going to be a net negative for providers.

但我認為，從長遠來看，我們認為，即使不是有所領先，至少也是完整的。從我的角度來看，好消息是基於我所看到的重新確定數據，雖然有很多人被重新確定，但其中很多重新確定，其中很大一部分更多是出於行政原因。他們的文件不是最新的，他們的地址也不是最新的，無論是什麼。因此，感覺這些人將能夠很快重新獲得醫療補助的角色。因此，從長遠來看，影響可能不會像我們想像的那麼大。但同樣，我們的觀點是，從長遠來看，短期內可能存在一些不確定性，我認為這不會對提供商產生真正的負面影響。

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

我們的下一個問題來自美國銀行的 Kevin Fischbeck。

I want to go back to, I guess, Marc's comments about both segments starting to transition to that post-pandemic world. Do you guys -- how are you thinking about what the company's two businesses look like in that world? Is it right to just assume that from a margin perspective, things look like 2018, 2019, is there a reason to believe that margins might be higher or lower over time? And how do you think about that path and the timing of getting to whatever that normalization is?

我想我想回到馬克對這兩個領域開始過渡到大流行後世界的評論。你們覺得公司的兩項業務在那個世界裡是什麼樣子的？假設從利潤率的角度來看，情況就像 2018 年、2019 年，是否有理由相信隨著時間的推移，利潤率可能會更高或更低？您如何看待這條道路以及實現正常化的時機？

Yes. I think the answer, Kevin, is a little bit different for each of the segments. I think -- and I think we touched on this to some degree in the call today, but certainly in previous calls as well. I think on the behavioral side, our view is that margins during the pandemic, particularly were diminished or negatively impacted by the labor scarcity. And again, the argument goes that as we are able to hire more people, we'll be able to create and really not create but exhaust more of the unmet demand that's been out there. And I think our view on behavioral is not only should we be able to return to 2019 margins ultimately, but to return to sort of peak behavioral margins, we'd probably go back to 2014 or 2015.

是的。凱文，我認為每個細分市場的答案都略有不同。我認為——而且我認為我們在今天的電話會議中在某種程度上談到了這一點，但在之前的電話會議中肯定也是如此。我認為在行為方面，我們的觀點是，大流行期間的利潤尤其受到勞動力短缺的減少或負面影響。再次，爭論認為，當我們能夠僱用更多的人時，我們將能夠創造（實際上不是創造而是耗盡更多未滿足的需求）。我認為我們對行為利潤的看法不僅是我們最終應該能夠回到 2019 年的利潤率，而且要回到行為利潤率的峰值，我們可能會回到 2014 年或 2015 年。

Now just to be clear, when I say that, I mean, I don't think that's an immediate. I don't think that happens obviously in the next quarter or 2. But I think it is this sort of gradual trajectory of relatively robust top line growth and relatively fixed and semi-fixed expenses that allow us to do that.

現在要澄清的是，當我這麼說時，我的意思是，我不認為這是立竿見影的。我認為這種情況不會在下一季度或第二季度明顯發生。但我認為正是這種相對強勁的營收增長和相對固定和半固定費用的漸進軌跡使我們能夠做到這一點。

I think on the acute side, it's a bit -- a little bit more of a mix story. There was certainly some benefit to the acute care business from the pandemic itself from the acuity of the COVID patients, from the special reimbursement that we received related to COVID patients, et cetera. And so, I think it's a little bit more challenging for the acute business to get back to those pre-pandemic margins. Because they've got to replace a lot of that, I'm going to say, COVID and patient-related benefit.

我認為從尖銳的角度來看，這有點像一個混合故事。疫情本身、新冠患者的病情嚴重程度、我們收到的與新冠患者相關的特別報銷等等，肯定會給急症護理業務帶來一些好處。因此，我認為對於敏感業務來說，要恢復到大流行前的利潤率更具挑戰性。因為他們必須取代很多，我想說的是，新冠病毒和與患者相關的福利。

Now clearly, they've been doing that over the last few quarters. And again, this gets back to, I think, a question of how sustainable this higher level of acute care volume is going to be. But again, pretty much -- pretty similar. I think we certainly feel like we're 400, 500 basis points on the acute side, below where our pre-pandemic margins were, as Marc -- Marc's comments in his prepared remarks where we got 60 basis points of that back in Q2. We view that as a first step, which we hope to sustain for many more quarters to get back there or get close to pre-pandemic margins.

顯然，他們在過去幾個季度一直在這樣做。我認為，這又回到了一個問題：這種更高水平的急症護理量將如何持續。但同樣，非常——非常相似。我認為我們確實感覺我們的利率在嚴重方面下降了 400、500 個基點，低於大流行前的利潤率，正如馬克在他準備好的講話中所說的那樣，我們在第二季度得到了 60 個基點。我們認為這是第一步，我們希望能夠維持更多季度，以恢復到這一水平或接近大流行前的利潤率。

Yes. So it sounds to me like and to some degree in both cases, it's the volume number that's going to get you back to where you were. I guess, the behavioral one makes sense, labor is a constraint you fix that. The Q1 though, it's still a little bit unclear to me. I understand the concept of pent-up demand, but when you just finally got above 2019 levels when historically, you've been growing volumes a couple of percent per year, kind of well below that long-term trend line. What is it that makes you cautious to say that you wouldn't get back to that long-term trend line? Aren't the population growth, demographics and fundamental demand drivers in your markets really unchanged? So why do you get concerned at this as a bolus rather than the new normal?

是的。所以在我看來，在某種程度上，在這兩種情況下，音量數字會讓你回到原來的位置。我想，行為方面是有道理的，勞動力是你解決這個問題的一個限制。不過，Q1 對我來說仍然有點不清楚。我理解被壓抑的需求的概念，但當你最終超過 2019 年的歷史水平時，你的銷量每年都會增長幾個百分點，遠低於長期趨勢線。是什麼讓您謹慎地說不會回到長期趨勢線？你們市場的人口增長、人口結構和基本需求驅動因素難道真的沒有改變嗎？那麼，為什麼你會擔心這是一種補充療法而不是新常態呢？

Yes. And again, I'm not -- I don't think we've -- in any way, given up the hope that we can get back to acute care margins -- pre-pandemic acute care margins. I'm simply suggesting that I think, the recovery or the path to recovery is a little more complicated on the acute side because there were some benefits from the pandemic that they just clearly were not on the behavioral side. The pandemic really had only negative consequences for our behavioral business. And therefore, I think recovery from the pandemic is sort of steeper and more robust and quicker, quite frankly, on the behavioral side than it is on the acute side.

是的。再說一次，我不——我認為我們——以任何方式放棄希望，我們可以回到急症護理利潤——大流行前的急症護理利潤。我只是想說，我認為，復甦或複甦之路在急性方面要復雜一些，因為大流行帶來了一些好處，但它們顯然不屬於行為方面。這場流行病確實對我們的行為業務產生了負面影響。因此，坦率地說，我認為從行為方面來看，從大流行中恢復的速度比急性方面更陡峭、更強勁、更快。

Look, I think what you're seeing is some pretty rapid recovery on the acute side. But again, it's being driven by what I think we would argue are probably some level of extraordinary volumes that will moderate some. But look, I think if you look at the acute care business model and earnings trajectory over an extended period of time with kind of mid-single-digit revenue growth in that 5% or 6% range we have generally been able to produce EBITDA growth, margin improvement, et cetera. And I don't think there's any reason we can't sustain that level of top line growth for the foreseeable future. I do think it may take us a little bit longer to get there than it will on the behavioral side.

聽著，我認為你所看到的是急性方面的快速恢復。但同樣，我認為我們認為，這可能是由某種程度的非凡交易量推動的，這可能會緩和一些。但是，我認為，如果你觀察長期的急症護理商業模式和盈利軌跡，收入增長在 5% 或 6% 範圍內，我們通常能夠實現 EBITDA 增長、利潤率改善等等。我認為我們沒有任何理由不能在可預見的未來維持這種收入增長水平。我確實認為我們可能需要比行為方面更長的時間才能實現這一目標。

Okay. All right. So I think I got it, but just to make sure to [decide all up,] you're not saying that this year's volumes become a headwind to next year because there's some sort of unsustainable bolus. It's -- this is probably a good base, but we just shouldn't assume 7% volume growth, we should assume from here more normalized volume growth? Or are you saying that there could be a headwind next year from a comp perspective?

好的。好的。所以我想我明白了，但為了確保[全部決定]，你並不是說今年的銷量會成為明年的逆風，因為存在某種不可持續的推注。這可能是一個很好的基礎，但我們不應該假設 7% 的銷量增長，我們應該從這裡假設更正常化的銷量增長？或者你是說從公司的角度來看明年可能會出現逆風？

Yes. Again, hard to know, Kevin, but we had 10% revenue growth, obviously, in this quarter. Again, that's at a historically high level. I don't -- again, I'm not giving 2024 guidance at this point, but I don't know that we'll be able to sustain that level of revenue growth. Two things. I think the level of revenue growth probably moderates a little bit. I think the makeup of that revenue growth changes to somewhat less volume, somewhat more acuity in pricing. But I think, again, if that 10% revenue growth moderates to 6% or 7%, I still think that's a model in which we're likely to see increased EBITDA and margin expansion.

是的。凱文，這又很難知道，但很明顯，本季度我們的收入增長了 10%。這再次處於歷史高位。我不會——再說一遍，我目前不會給出 2024 年的指導，但我不知道我們是否能夠維持這種收入增長水平。兩件事情。我認為收入增長水平可能會有所放緩。我認為收入增長的構成發生了變化，即銷量有所減少，定價更加敏銳。但我再次認為，如果 10% 的收入增長放緩至 6% 或 7%，我仍然認為在這種模式下，我們可能會看到 EBITDA 增加和利潤率擴張。

We have a question from Stephen Baxter with Wells Fargo.

我們有富國銀行斯蒂芬·巴克斯特 (Stephen Baxter) 提出的問題。

A follow-up on an earlier question. I wanted to see if you could expand a little bit more on the behavioral margins in the quarter. Usually pre-COVID margins increased sequentially in the second quarter. Obviously, you had a different experience this quarter with SWB and other OpEx as a percent of revenue up sequentially. Wondering what drove those increases? And how did margins internally compare to your expectations? And do you think we should see something closer to typical seasonality in the balance of the year?

對先前問題的跟進。我想看看你們是否可以在本季度進一步擴大行為利潤。通常，新冠疫情爆發前的利潤率在第二季度會連續增長。顯然，本季度 SWB 和其他運營支出佔收入的百分比有所上升，這給您帶來了不同的體驗。想知道是什麼推動了這些增長？內部利潤率與您的預期相比如何？您認為我們應該在一年中的其餘時間看到更接近典型季節性的東西嗎？

Yes. And operator, I'm just going to make the point, this is going to have to be our last question. So we had a few non-recurring items in the quarter. We had a loss on disposal of assets that were about $3 million. We had an unfavorable exchange rate, which was affecting us in the U.K. by a couple of million dollars. But just generally, I think we saw salaries increased a little bit more than we expected in the quarter. And this is a point I was making or in responding to an earlier question. I mean, I think generally, our ability to hire people and fill these vacant positions is a positive development. In the short run, it can be somewhat inefficient. We have a lot of people in orientation and training.

是的。接線員，我只想指出這一點，這將是我們的最後一個問題。因此，本季度我們有一些非經常性項目。我們因資產處置而損失了約 300 萬美元。我們的匯率不利，這給我們在英國的損失造成了數百萬美元的影響。但總的來說，我認為本季度的薪資增幅略高於我們的預期。這是我在回答之前的問題時提出的觀點。我的意思是，我認為總的來說，我們僱用人員和填補這些空缺職位的能力是一個積極的發展。從短期來看，它的效率可能會有些低。我們有很多人在接受指導和培訓。

A lot of these people that we're hiring are somewhat less experienced and less trained and particularly in behavioral care, then were used to historically. And that creates a little bit of inefficiency again, in the short run, I think in the long run, and that's why I'm suggesting to people not to focus so much on just the second quarter, but on the first 6 months of the year or the last 4 months -- of the last 4 quarters where we've really been emerging from the pandemic not being impacted by COVID, being able to hire people.

我們僱用的許多人經驗不足，訓練不足，特別是在行為護理方面，然後在歷史上習慣了。從短期來看，我認為從長遠來看，這再次造成了一點效率低下，這就是為什麼我建議人們不要只關注第二季度，而應該關註今年的前 6 個月。今年或過去 4 個月——在過去 4 個季度中，我們確實擺脫了疫情的影響，沒有受到新冠病毒的影響，能夠僱用員工。

And I think the -- broadly, the results there show that we're going to continue to grow the top line, but also generate the efficiencies that we think generally come with that top line growth. And I think that's still fundamentally our belief. So I think that's the way we're looking at the business. Thanks for your question. And operator, I think we're going to have to stop at this point in time.

我認為，從廣義上講，那裡的結果表明，我們將繼續增加收入，但也會產生我們認為通常伴隨收入增長而來的效率。我認為這仍然是我們的根本信念。所以我認為這就是我們看待業務的方式。謝謝你的提問。接線員，我想我們必須在這個時間點停下來。

Okay. I'd like to turn it back to Steve Filton for any closing remarks.

好的。我想請史蒂夫·菲爾頓（Steve Filton）發表結束語。

Yes, just to thank everybody for their time this morning, and we look forward to speaking with everybody again after our third quarter.

是的，只是為了感謝大家今天早上抽出時間，我們期待在第三季度之後再次與大家交談。

This concludes today's conference call. Thank you for participating. You may now disconnect.

今天的電話會議到此結束。感謝您的參與。您現在可以斷開連接。