環球健康 (UHS) 2024 Q4 法說會逐字稿

Good day, and thank you for standing by. Welcome to the Fourth Quarter 2024 Universal Health Services Earnings Conference Call. (Operator Instructions) Please be advised today's conference is being recorded.

您好，感謝您的支持。歡迎參加 2024 年第四季全民健康服務收益電話會議。（操作員指示）請注意，今天的會議正在錄音。

I would now like to hand the conference over to your speaker today, Steve Filton, Executive Vice President and CFO. Please go ahead.

現在，我想將會議交給今天的發言人、執行副總裁兼財務長 Steve Filton。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 fourth quarter ended December 31, 2024.

謝謝，早安。馬克米勒 (Marc Miller) 今天早上也將加入我們。歡迎您閱讀截至 2024 年 12 月 31 日的第四季全民健康服務業績審查。

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. For anyone not familiar with the risks and uncertainties inherent in these forward-looking statements, I recommend a careful reading of the section on risk factors and forward-looking statements and Risk Factors in our Form 10-K for the year ended December 31, 2024.

在電話會議期間，我們將使用相信、預期、預計、估計等詞語以及代表預測、預期和前瞻性陳述的類似詞語。對於不熟悉這些前瞻性陳述所固有的風險和不確定性的任何人，我建議仔細閱讀我們截至 2024 年 12 月 31 日的 10-K 表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 certain 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 $4.96 for the fourth quarter of 2024. After adjusting for the impact of the items reflected on the supplemental schedule included in the press release, our adjusted net income attributable to UHS per diluted share of $4.92 for the quarter ended December 31, 2024.

在開始提問之前，我們想先強調某些發展和商業趨勢。正如我們昨晚的新聞稿中所討論的那樣，該公司報告 2024 年第四季歸屬於 UHS 的每股攤薄淨利潤為 4.96 美元。在調整新聞稿中補充時間表所反映專案的影響後，截至 2024 年 12 月 31 日的季度，我們歸屬於 UHS 的調整後每股攤薄淨利潤為 4.92 美元。

During the fourth quarter of 2024, on a same-facility basis, adjusted admissions to our acute care hospitals increased 2.2% over fourth quarter of prior year. Same-facility net revenues in our acute care hospital segment increased by 8.7% during the fourth quarter of 2024 as compared to last year's fourth quarter, driven primarily by a 5.3% increase in net revenue per adjusted admission.

2024 年第四季度，以相同設施計算，我們急診醫院的調整後入院人數比去年同期增加了 2.2%。2024 年第四季度，我們急診醫院部門的同設施淨收入與去年第四季度相比增長了 8.7%，主要原因是調整後入院淨收入增長了 5.3%。

Meanwhile, operating expenses continued to be well managed. The amount of premium paid in the quarter, for example, which declined from a peak of $153 million for the first quarter of 2022 was $60 million in the fourth quarter of 2024, remaining consistent with the previous two quarters. For the full year of 2024, our strong acute care revenues, combined with effective expense controls, resulted in a 13% increase in EBITDA even after excluding the growth in Medicaid supplemental payments.

同時，營業費用持續得到良好管理。例如，本季支付的保費金額從 2022 年第一季的 1.53 億美元的峰值下降到 2024 年第四季的 6,000 萬美元，與前兩個季度保持一致。就 2024 年全年而言，我們強勁的急性照護收入加上有效的費用控制，即使排除醫療補助補充支付的成長，EBITDA 仍成長了 13%。

During the fourth quarter, same-facility revenues at our behavioral health hospitals increased by 11.1%, driven primarily by an 8.7% increase in revenue per adjusted patient day. Excluding the year-over-year growth in Medicaid supplemental payments, the same facility revenue increase was 7.4%.

第四季度，我們行為健康醫院的同店營收成長了 11.1%，主要得益於調整後病患每日收入成長 8.7%。不包括醫療補助補充支付的同比增長，同一設施的收入增長了 7.4%。

Included in our operating results during the fourth quarter of 2024, were aggregate net incremental reimbursements of approximately $50 million recorded in connection with various state supplemental Medicaid programs, including $31 million of additional net reimbursements from the Nevada State directed payment program covering the six-month period of July 1, 2024 through December 31, 2024. These net reimbursements were more than the supplemental program projections included in our earnings guidance for the full year of 2024 as revised on July 24, 2024.

我們 2024 年第四季的營運業績包括與各州補充醫療補助計畫相關的總計約 5,000 萬美元的淨增量報銷，其中包括內華達州定向支付計畫的 3,100 萬美元額外淨報銷，涵蓋 2024 年 7 月 1 日至 2024 年 12 月 31 日的六個月期間。這些淨報銷金額超過了我們於 2024 年 7 月 24 日修訂的 2024 年全年獲利預測中包含的補充計畫預測。

As a result of unfavorable trends experienced during the past several years, during the fourth quarter of 2024, we recorded a $35 million increase to our reserves for self-insured professional and general liability claims. Our operating results for the full year of 2024 included a $79 million increase to our self-insured professional and liability reserves.

由於過去幾年的不利趨勢，在 2024 年第四季度，我們的自保專業和一般責任索賠準備金增加了 3500 萬美元。我們 2024 年全年的經營業績包括我們的自保專業和責任準備金增加了 7,900 萬美元。

Our cash generated from operating activities was $658 million during the fourth quarter of 2024 as compared to $452 million during the same quarter in 2023 and $2.067 billion during the full year of 2024 as compared to $1.268 billion during 2023. We spent $944 million on capital expenditures during 2024, which was consistent with our original forecast for the year.

2024 年第四季度，我們的經營活動產生的現金為 6.58 億美元，而 2023 年同期為 4.52 億美元；2024 年全年為 20.67 億美元，而 2023 年為 12.68 億美元。我們在 2024 年的資本支出為 9.44 億美元，這與我們對該年度的初步預測一致。

In our acute division, we opened West Henderson Hospital in Las Vegas late in 2024 and plan to open Cedar Hill Medical Center in Washington, D.C in the next two months. We forecast that these facilities will be EBITDA positive in 2025 on a combined basis. In both of our segments, we continue to invest in expansion of our outpatient presence and the broadening of our continuum of care.

在我們的急性病部門，我們於 2024 年底在拉斯維加斯開設了西亨德森醫院，並計劃在未來兩個月內在華盛頓特區開設雪松山醫療中心。我們預測，這些設施到 2025 年的合併 EBITDA 將為正值。在我們的兩個部門中，我們都在繼續投資以擴大我們的門診服務範圍並擴大我們的護理服務範圍。

For the full year of 2024, we acquired $599 million of our own shares pursuant to our share repurchase program. Since January 1, 2019, we have repurchased more than 29.2 million shares representing approximately 32% of our shares outstanding as of that date.

2024 年全年，我們根據股票回購計畫回購了價值 5.99 億美元的自有股票。自 2019 年 1 月 1 日以來，我們已回購超過 2,920 萬股，約佔截至該日已發行股票的 32%。

As of December 31, 2024, we had $1.17 billion of aggregate available borrowing capacity pursuant to our $1.3 billion revolving credit facility.

截至 2024 年 12 月 31 日，根據我們的 13 億美元循環信貸安排，我們擁有 11.7 億美元的總可用借款能力。

The core operating assumptions underlying our 2025 operating results forecast, which was provided in last night's release, largely reflect the historical trends in their respective businesses with EBITDA growth in the mid-single digits. We expect continued improvement in salary and wages and general cost trends that will remain largely stable in 2025. As noted in our 10-K filed yesterday, our 2025 operating results forecast excludes any supplemental Medicaid revenues in Tennessee and the District of Colombia, pending CMS approval of those programs.

我們昨晚發布的 2025 年營運績效預測所依據的核心營運假設在很大程度上反映了各自業務的歷史趨勢，EBITDA 成長率為中等個位數。我們預計，2025年薪資和整體成本趨勢將持續改善並基本保持穩定。正如我們昨天提交的 10-K 文件中所述，我們對 2025 年經營業績的預測不包括田納西州和哥倫比亞特區的任何補充醫療補助收入，需等待 CMS 批准這些計劃。

As the 10-K schedule reflects, our 2020 forecast -- 2025 forecast assumes total consolidated Medicaid supplemental payments will decrease slightly as compared to 2024. We believe demand for our behavioral services remains solid, and our same facility adjusted patient day growth in 2025 at our facilities located in the US is forecasted to be in the 2.5% to 3% range. We've accelerated technology investments in our behavioral hospitals to improve patient care, including electronic health record implementations and expanded use of patient monitoring automation.

正如 10-K 時間表所反映的那樣，我們對 2020 年的預測 - 2025 年的預測假設合併後的醫療補助補充支付總額將與 2024 年相比略有下降。我們相信，對我們的行為服務的需求仍然強勁，預計 2025 年我們位於美國的設施的同一設施調整後患者日增長率將在 2.5% 至 3% 之間。我們加快了對行為醫院的技術投資，以改善病患護理，包括電子健康記錄實施和擴大病患監測自動化的使用。

We acknowledge that the current political environment has created a level of uncertainty, especially as it relates to ongoing Medicaid reimbursement. Our 2025 forecast is based on current Medicaid reimbursement projections in connection with various programs that could be subject to change. In our acute business segment, we are pleased that 80% of our hospitals currently have an A or B rating well above the national average. And in our behavioral division, we saw meaningfully significant improvement in patient experience scores in 2024.

我們承認，當前的政治環境造成了一定程度的不確定性，特別是與正在進行的醫療補助報銷相關的不確定性。我們對 2025 年的預測是基於與各種可能發生變化的計劃相關的當前醫療補助報銷預測。在我們的急性業務部門，我們很高興看到我們 80% 的醫院目前擁有 A 或 B 級評級，遠高於全國平均水平。在我們的行為部門，我們看到 2024 年患者體驗評分顯著提高。

We are focusing on continued improvement of these metrics in 2025. We are now pleased to answer your questions.

我們致力於在 2025 年繼續改善這些指標。我們現在很高興回答您的問題。

(Operator Instructions) Andrew Mok, Barclays.

(操作員指示) 巴克萊銀行的 Andrew Mok。

The 2025 EBITDA guidance is up 5% to 11%, which is higher than typical growth rates despite state supplemental payments forecasted to be down year-over-year. So I'd love to hear a little bit more color on what's driving the higher underlying growth in 2025?

2025 年 EBITDA 預期將上漲 5% 至 11%，儘管預計國家補貼支付將同比下降，但仍高於典型的成長率。所以，我很想進一步了解一下，是什麼推動了 2025 年更高潛在成長？

Sure, Andrew. Well, at least a couple of things. I mean, number one, just the core growth -- core EBITDA growth that Marc talked about in the two segments, I think is being driven by a return as he described to sort of historical norms, solid volume growth, pretty robust pricing and I think very effective expense control. And I think we don't have the pressures on our operating expenses that were such a drag during the COVID years, the wage inflation, the very high use of premium pay, not necessarily related to COVID, but on the acute side, the professional fee expense pressures that we faced in 2023, et cetera. So I think as our commentary reflected in our prepared comments that we're expecting a much more sort of stable operating environment outside of potentially the reimbursement changes that are being discussed at a pretty high level.

當然，安德魯。嗯，至少有幾件事。我的意思是，第一，馬克在兩個部分中談到的核心成長——核心 EBITDA 成長，我認為是由他所描述的歷史常態回報所驅動，包括穩健的銷售成長、相當強勁的定價，以及非常有效的費用控制。而且我認為，我們的營運費用沒有受到疫情期間的拖累，薪資上漲、加班費的大量使用（這些不一定與疫情有關，但在嚴重方面，我們在 2023 年面臨的專業費用支出壓力等等）。因此，我認為，正如我們的評論在我們準備好的評論中所反映的那樣，我們期待除了正在相當高的層次上討論的潛在報銷變化之外，還會有一個更加穩定的運營環境。

In addition to that, as I think our comments indicated, we incurred a significant amount of incremental malpractice expense in 2024, that we are hoping will not recur in 2025. And so that's another source of upside in the earnings. And then -- and I know you're really talking about operating earnings, but from an EPS perspective, we then get a boost from a reduction in interest rate or interest expense as well as a continued reduction in our share count.

除此之外，我認為我們的評​​論表明，我們在 2024 年發生了大量增量醫療事故費用，我們希望這種費用不會在 2025 年再次發生。這也是獲利成長的另一個來源。然後 - 我知道您實際上談論的是營業收入，但從每股收益的角度來看，我們會從利率或利息支出的降低以及股票數量的持續減少中獲得提振。

Great. And then maybe just a follow-up. The guidance range, I think, is $127 million wide, which is higher than previous years despite better operations and visibility. So why is the range of outcomes here wider than usual? And where are the puts and takes within that range?

偉大的。然後可能只是一個後續行動。我認為，指導範圍是 1.27 億美元，儘管營運和可見度有所改善，但仍高於前幾年。那為什麼這裡的結果範圍比平常更廣呢？那麼該範圍內的看跌期權和看漲期權在哪裡呢？

Yes. I mean I think -- and I think Marc commented on this in the prepared remarks, we acknowledge that the items that are sort of beyond our control in terms of government reimbursement and potential changes in that regard, we tried to provide some level of caution and conservatism in the guidance. And I think part of that is the wider range that we've provided.

是的。我的意思是，我認為——我認為馬克在準備好的評論中對此發表了評論，我們承認，在政府報銷和相關潛在變化方面，有些項目是我們無法控制的，我們試圖在指導中提供一定程度的謹慎和保守。我認為其中一部分原因是我們提供的服務範圍更加廣泛。

Ben Hendrix, RBC Capital Markets.

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

Just wanted to go back to the slight decrease in DPP that you're foreseeing for next year. Is there any way to parse out how much of that is just overall conservatism versus foreseeable changes in specific programs?

我只是想回過頭來談談您預測明年 DPP 會略微下降的問題。有沒有辦法分析其中有多少是整體保守主義，有多少是具體專案中可預見的變化？

Yes. Ben, I think the main reason for the decline is, as we've disclosed in each quarter during 2024, we've recognized some DPP payments that were related to prior periods. And I think that's the main reason for the decline is that some of the DPP payments and DPP revenues that we recognized in 2024 really related to prior periods. There may be some programs that had small declines next year, but I think that's the main reason driving the decline.

是的。本，我認為下降的主要原因是，正如我們在 2024 年每個季度所披露的那樣，我們確認了一些與前期相關的 DPP 付款。我認為下降的主要原因是我們在 2024 年確認的部分 DPP 付款和 DPP 收入實際上與之前的時期有關。明年有些項目可能會出現小幅下滑，但我認為這是下滑的主要原因。

And then just to follow up on the malpractice reserves. Just how are you thinking overall about adequacy at this point? Are we at a point where there is a reasonable cushion? Or are there trends that you're seeing now that could increase the probability of another adjustment this year?

然後只是跟進醫療事故準備。您現在對於充分性整體有何看法？我們是否已經到達了合理緩衝的階段？或者您現在看到的趨勢可能會增加今年再次進行調整的可能性？

Yes. So I think it's worth noting that in establishing RML practice reserves, we use a third-party actuary who evaluates our claims history, pending claims, industry trends, et cetera. It's a relatively comprehensive analysis. Historically, we've tried to set and establish our reserves sort of at the midpoint of the range that our third-party actually provides to us. Given some of the volatility in that area and some of the pressure, we tried this year to move a little bit towards the higher end of the range. So we are hoping that there's an element of conservatism built into those reserves and that there won't be a need for another uptick in 2025. Obviously, we can't be assured of that, but we feel like we've taken a pretty prudent position here.

是的。因此我認為值得注意的是，在建立 RML 實踐儲備時，我們會使用第三方精算師來評估我們的索賠歷史、未決索賠、行業趨勢等。分析的比較全面。從歷史上看，我們一直試圖將我們的儲備設定並確立在第三方實際向我們提供的範圍的中間點。考慮到該地區的一些波動性和一些壓力，我們今年嘗試稍微向該範圍的高端靠攏。因此，我們希望這些儲備中存在一定的保守因素，並且 2025 年不需要再次增加。顯然，我們不能保證這一點，但我們覺得我們在這裡採取了非常謹慎的立場。

Ann Hynes, Mizuho.

安海因斯（Ann Hynes）、瑞穗（Mizuho）。

Could you talk about behavioral same-store patient days? I remember thinking and maybe I'm remembering incorrectly that you thought you would be exiting 2024 at about 2%, which I believe was below 2%. So what was the driver of that? And I think you said in guidance, you assume it's going to accelerate to 2.5% to 3%. Can you just tell us what the drivers of that acceleration is?

能談談行為同店患者日數嗎？我記得我曾經想過——也許是我記錯了——你認為到 2024 年你的利率將達到 2% 左右，但我認為實際利率低於 2%。那麼，造成這種情況的原因是什麼呢？我認為您在指導中說過，您假設它將加速到 2.5% 到 3%。您能告訴我們這種加速的驅動因素是什麼嗎？

Yes. So -- and in fact, Ann, I think for the first two-thirds of the quarter, October, November, we were tracking sort of in that 2.5% range and felt pretty good about things. I remember, and honestly probably my last public appearance was at your conference in early December, and I remember telling people that I thought we were doing well, except it was always hard to predict what would happen in the back half of December with the holidays. That's always sort of unpredictable. And in fact, we did see a fairly dramatic decline in our patient day volumes in behavioral in the back half of December.

是的。所以 — — 事實上，安，我認為在本季度的前三分之二時間，即 10 月和 11 月，我們的增長率一直保持在 2.5% 左右，而且感覺相當不錯。我記得，老實說，我最後一次公開露面可能是在 12 月初的會議上，我記得我告訴人們我認為我們做得很好，只是很難預測 12 月下半月假期會發生什麼。這總是有點難以預測的。事實上，我們確實看到 12 月下半月行為的患者日數急劇下降。

I think having the Christmas and New Year's holidays right in the middle of the week, on a Wednesday, really sort of made those last two weeks, particularly for that child and adolescent population a much softer result than we were anticipating. And quite frankly, we've experienced historically. Volumes tended to sort of rebound in early January, which led us to believe that, that was really kind of a temporary transient sort of thing. We've struggled a little bit over the last month mainly because of difficult winter weather around the country, particularly in places that, quite frankly, are not generally used to or equipped for winter weather.

我認為，聖誕節和新年假期正好在周三，這確實使得最後兩週的銷售額，特別是對於兒童和青少年群體來說，比我們預期的要低得多。坦白說，我們在歷史上也經歷過這樣的事。1 月初交易量趨於反彈，這讓我們相信，這實際上是一種暫時的、短暫的現象。過去一個月我們遇到了一些困難，主要是因為全國各地的冬季天氣都很惡劣，特別是那些坦率地說通常不習慣或沒有能力應對冬季天氣的地方。

We've seen school closures in a pretty large scale in places like Virginia and Tennessee and Kentucky and Mississippi places that don't generally close during the wintertime. But again, I think we feel that those are transient sorts of dynamics and that for the full year, getting to that 2.5%, 3% patient day growth should not be sort of a heroic metric to achieve.

我們發現維吉尼亞州、田納西州、肯塔基州和密西西比州等地學校大規模停課，而這些地方冬季通常不會停課。但是，我認為，我們認為這些都是暫時的動態，對於全年而言，實現 2.5% 到 3% 的患者日增長率並不應該是一項難以實現的指標。

Great. And then staying on the behavioral theme, Medicaid rates have been good for Universal in the industry. Can you remind us what they actually were in 2024 and what you expect in 2025?

偉大的。然後繼續行為主題，醫療補助率對環球影業來說在業界一直很有利。您能否提醒我們 2024 年的實際情況以及您對 2025 年的預期是什麼？

Yes. I mean, so what's built into our guidance for 2025 is, I would say, same-store behavioral revenue growth in the 6%, 7%, 8% range. And again, I think that's sort of 2.5% to 3% volume and 3% to 4% price. To be fair, that -- and that 3% to 4% price is exclusive of any changes in supplemental payments. That's just what I would describe as core pricing. Our core pricing, and I think that's sort of the thrust of your question, has generally been better than that over the last several years, and we'll continue to press our payors and hope to do better than that. So if there's an element of conservatism in our behavioral projections, it's probably on the pricing side of the equation.

是的。我的意思是，我們對 2025 年的預期是，同店行為收入成長率將在 6%、7%、8% 之間。再說一次，我認為這是 2.5% 到 3% 的數量和 3% 到 4% 的價格。公平地說，3% 到 4% 的價格不包括補充支付的任何變化。這就是我所描述的核心定價。我們的核心定價（我認為這也是您問題的重點）在過去幾年中總體上一直比預期要好，我們將繼續向付款人施壓，並希望做得更好。因此，如果我們的行為預測中存在保守因素，那麼它可能出現在定價方面。

Justin Lake, Wolfe Research.

賈斯汀·萊克（Justin Lake），沃爾夫研究公司。

I wanted to move over to the policy stuff. Specifically, it looks like the bigger ticket items like caps are off the table on Medicaid, some discussion that maybe provider taxes would be a place they would pivot to. I know you sophisticated on this stuff, what are you hearing there in terms of the appetite to look at provider taxes as an area of savings within this legislation?

我想要轉向政策方面的事情。具體來說，看起來醫療補助計劃中不再考慮諸如上限之類的大件物品，有人討論說，也許供應商稅是他們轉向的一個領域。我知道您對這些事情很了解，那麼就將供應商稅視為該立法的一個節約領域而言，您聽到了什麼消息？

You start.

你開始。

Yes. So Justin, I would say, and I think you know this, I mean, I think the administration has really made no sort of definitive public statements about provider taxes. The point that we've made and I think our peer companies have made is there appears to be wide support for these provider tax or directed payment programs around the country in a large number of states, including states of all political strikes.

是的。所以賈斯汀，我想說，我想你知道這一點，我的意思是，我認為政府實際上並沒有就供應商稅做出任何明確的公開聲明。我們所提出的觀點以及我認為我們的同行公司也提出的觀點是，全國許多州，包括所有政治罷工州，似乎都廣泛支持這些提供者稅或定向支付計劃。

And so I think one of the things that we're learning or observing from this debate within Congress over the budget bill is that there is a fair amount of support, again, I think, throughout the country for Medicaid programs and protecting Medicaid programs. There hasn't been a whole lot of discussion specifically about direct to payment programs but we believe that there is a significant amount of political support at the state level for those programs in a great many states.

因此，我認為，我們從國會有關預算法案的辯論中了解到或觀察到的一件事是，我認為，全國各地都對醫療補助計劃和保護醫療補助計劃給予了相當多的支持。關於直接支付計劃的具體討論還沒有很多，但我們相信，許多州在州一級都對這些計劃給予了大量政治支持。

And I just want to add to what Steve just said there because we're clearly monitoring this very closely, talking off the record with many of the folks, not just in Washington, but in the States. And I think that's a key point. The folks in Congress are hearing from the governor's offices in many of these states.

我只想補充史蒂夫剛才說的話，因為我們顯然在密切關注此事，並與許多人進行了私下交談，不僅在華盛頓，而且在美國。我認為這是關鍵點。國會議員們正在聽取許多州州長辦公室的意見。

And like Steve said, it's a bipartisan effort. It's not just the democratic states but it's many of the large Republican-led states as well. So that tends to suggest that the pushback is significant. And I think we're in a better position than sometimes what we see on the news.

正如史蒂夫所說，這是兩黨共同的努力。不只是民主黨州，許多共和黨主導的大州也是如此。這往往表示反擊力度很大。我認為我們的情況比有時我們在新聞中看到的要好。

Great. And then just another question on DPP. The -- I know you've got some dollars potentially coming in D.C., in Tennessee. You guys do a great job of giving color on that in your 10-K. It looks like you're not projecting that. Anything to read into that for 2025? Like any change in your level of confidence that this stuff comes through at the end of the day?

偉大的。然後還有一個關於 DPP 的問題。我知道你們可能會從華盛頓特區和田納西州獲得一些資金。你們在 10-K 中對此進行了出色的闡述。看起來你並沒有預測到這一點。對於 2025 年有什麼可以解讀的嗎？例如，對於最終能實現這些目標，您的信心程度有什麼改變嗎？

So we believe that our 2025 forecast reflects our historical practices when it comes to DPP. And that is once a program has been approved and is in place even though all these programs have to be renewed and reapproved annually, we presume that programs that have been approved historically will continue to be approved and they remain in our guide. The two programs you referenced Tennessee and Washington, D.C are new programs that have only been partially approved. So for Tennessee, the actual program has been approved and the dollars have been approved for the back half of 2024, but it still requires CMS approval of the 1115 Medicaid waiver. And so until full approval is granted, we haven't included any of those Tennessee dollars.

因此，我們認為，我們對 2025 年的預測反映了我們在 DPP 的歷史實踐。一旦某個計劃獲得批准並實施，儘管所有這些計劃都必須每年更新和重新批准，但我們推測歷史上已獲批准的計劃將繼續獲得批准，並且仍將保留在我們的指南中。您提到的田納西州和華盛頓特區的兩個項目都是僅獲得部分批准的新項目。因此對於田納西州而言，實際計劃已獲批准，2024 年下半年的資金也已獲批准，但仍需要 CMS 批准 1115 醫療補助豁免。因此，在獲得完全批准之前，我們不會對田納西州的任何資金進行投資。

The DC approval is pending in its entirety. We haven't included any of those dollars either in Q4 or in our 2025 guidance. In both cases, the state or the district hospital associations tell us and tell their constituents that they've not heard anything from CMS suggesting that the programs are problematic in any way in their structure. They expect them to be approved. There's some uncertainty as sort of what the timing of that.

目前 DC 的批准正在等待全部結果。我們在第四季或 2025 年指引中均未包含這些資金。在這兩種情況下，州或地區醫院協會都告訴我們並告訴他們的選民，他們沒有從 CMS 聽到任何消息，表明這些項目在結構上有任何問題。他們期望得到批准。至於具體時間如何，仍存在一些不確定性。

But yes, I mean, I will tell you the expectation of the hospital associations themselves is that, that approvals are pending and have just sort of been slowed by the transition of administration, we'll see. But -- but again, nothing to be read into how we've handled it other than in our mind, consistent with the way we've handled these DPP programs from the beginning.

但是的，我的意思是，我會告訴你，醫院協會本身的期望是，批准正在等待中，只是由於行政過渡而有所放緩，我們拭目以待。但是 — — 但再說一次，除了在我們的腦海中，沒有其他可以解讀我們處理這個問題的方式，這與我們從一開始就處理這些 DPP 計劃的方式一致。

Pito Chickering, Deutsche Bank.

皮托·奇克林，德意志銀行。

Leverage is now below sort of 2 times here. Can you just remind us what your targeted leverage ratios are here? And today, using all of your free cash flow to do share repurchases. At what point do you start borrowing to maintain the leverage ratios and using those borrowings to increase your share repurchases?

現在槓桿率大概在2倍以下。您能否提醒我們一下您的目標槓桿率是多少？今天，使用所有的自由現金流來進行股票回購。您什麼時候開始借款來維持槓桿率，並使用這些借款來增加您的股票回購？

Thanks, Pito. So I think we have historically operated at a leverage level, generally in sort of the high 2s, approaching 3. We're certainly comfortable at a level like that. And I would think that that's where we would generally target things in the future. I think our guidance for the year presumes that we'll use the bulk of our free cash flow for share repurchase. The possibility that we could lever up and use even more than that, I think is certainly a real possibility and not something we've decided today. But again, in our guidance, I think we were reasonably conservative in thinking that our share repurchase levels would be around what they've been in the last several years in that sort of $600 million to $800 million range.

謝謝，Pito。所以我認為，從歷史上看，我們的槓桿水平通常都在 2% 左右，接近 3%。我們對於這樣的水平確實感到滿意。我認為這正是我們未來的主要目標。我認為，我們今年的指導假設我們將使用大部分自由現金流用於股票回購。我認為，我們有可能利用更多資金，這當然是真正有可能的，而不是我們今天就決定的事情。但是，在我們的指導中，我認為我們相當保守地認為我們的股票回購水準將與過去幾年的水準大致相同，即 6 億至 8 億美元。

Okay. But -- so look intellectually, we could be thinking about you guys starting to actually using leverage here to at least maintaining some leverage above where it is today, if you come with the macro level to start increasing beyond just free cash flow?

好的。但是——從理性的角度看，我們可以考慮你們是否開始實際使用槓桿，至少將槓桿率維持在目前水平之上，如果從宏觀層面開始增加不僅僅是自由現金流呢？

No, I think that's fair. And I think that if you look at our historical practices, there certainly have been times where we have done that for sure.

不，我認為這很公平。我認為，如果你看看我們的歷史實踐，你會發現我們確實曾經這樣做過。

Okay. Fair enough. And then on behavioral, you guys closed two hospitals this quarter, how does it impact like your EBITDA when you close those facilities, how many other facilities do you look at for portfolio trimming for 2025? And with such a larger supply-demand and balance in behavioral, I guess, why is there a need to close any of these facilities?

好的。很公平。然後在行為方面，你們本季關閉了兩家醫院，關閉這些設施會對您的 EBITDA 產生什麼影響，您還考慮了多少其他設施來削減 2025 年的投資組合？我想，在供需如此之大和行為平衡的情況下，為什麼有必要關閉這些設施？

Yes. I think if someone wanted to take the time and for instance, take a look at our portfolio of behavioral facilities let's say, 10 years ago and where we are today, I think that you would find that portfolio rationalization is sort of an ongoing part of our behavioral strategy and that the portfolio of hospitals that we have today is different than it was 10 years ago. We had sold some facilities, we've consolidated a number of facilities. We sort of retooled facilities to provide different services. We've done any number of things.

是的。我認為如果有人願意花點時間，比如說，看看我們 10 年前的行為設施組合以及我們今天的狀況，我想你會發現組合合理化是我們行為策略的一個持續組成部分，而且我們今天的醫院組合與 10 年前不同。我們已經出售了一些設施，並合併了一些設施。我們對設施進行了重新調整，以提供不同的服務。我們做了很多事。

It's a large portfolio and generally an individual hospital is not material in the portfolio, so we don't necessarily disclose or discuss in detail when we do these things. But it's really that aspect of it. And when you ask sort of what's the rationale for that or what causes that, while we acknowledge or we would agree with your overall comment that I think behavioral demand has been strong during this period. Obviously, demand for particular services in a particular area, particular reimbursement dynamics, all those things can change in the interim.

這是一個龐大的投資組合，一般來說，單一醫院在投資組合中並不重要，所以我們在做這些事情時不一定會詳細披露或討論。但它確實就是這樣的。當您問到這種現象的原因是什麼或是什麼時，我們承認或同意您的整體評論，我認為在此期間行為需求一直很強勁。顯然，特定領域對特定服務的需求、特定的報銷動態等所有這些事情都可能在此期間發生變化。

And we do react to those things and effectively try and look at those facilities that are sort of least efficient, lesser returning and trying to determine whether they have kind of a path to getting sort of more towards the bell curve of performance. And if they don't, we look for potential exit strategies, which again could be closure, could be sale, could be consolidation, could be retooling, all those things, I think, are always on the table.

我們確實對這些事情做出了反應，並有效地嘗​​試和關注那些效率最低、回報率較低的設施，並試圖確定它們是否有辦法更接近性能鐘形曲線。如果他們不這樣做，我們就會尋找潛在的退出策略，可能是關閉，可能是出售，可能是合併，可能是重組，我認為，所有這些事情都是可以考慮的。

Joanna Gajuk, Bank of America.

美國銀行的喬安娜‧加朱克 (Joanna Gajuk)。

First because I don't know whether I missed it but yes, thanks for talking about your assumptions for your behavior segment growth for '25. But what do you assume for acute revenue growth, volume versus pricing?

首先，因為我不知道我是否錯過了，但是是的，感謝您談論您對'25 年行為細分增長的假設。但是，您對銷售和定價的急劇收入成長有何看法？

Yes. So I think the assumptions for the acute division are also mid-single-digit revenue growth, probably a little bit more modest, maybe in the 5%, 6% range. And I would say, split pretty evenly between price and volume. So the 2.5%, 3% adjusted admission growth, 2.5% to 3% pricing growth. And again, I think in both segments, in this environment where expenses have moderated, wage inflation has moderated. The use of premium pay is moderated, physician expenses have moderated, that mid-single-digit revenue growth in both divisions in our mind should be sufficient to allow us to grow EBITDA and expand margins.

是的。因此，我認為急性部門的收入成長假設也是中等個位數，可能稍微溫和一些，可能在 5% 到 6% 的範圍內。我想說的是，價格和數量之間的分配相當均勻。因此，調整後的入場費成長率為 2.5%、3%，定價成長率為 2.5% 至 3%。而且我認為，在這兩個領域，在支出已經緩和的環境下，薪資通膨也已經緩和。加班費的使用有所緩和，醫生的費用也有所減少，我們認為兩個部門的中等個位數收入增長應該足以讓我們實現 EBITDA 增長並擴大利潤率。

And I guess on wages, because I think the nationwide data on the wage growth for nursing shows some acceleration in the late 2024. Are you seeing that? Or is it just a function of some comp issue there?

我猜是關於工資的，因為我認為全國範圍內的護理工資增長數據顯示，2024 年末將會有所加速。你看到了嗎？或者這只是某些計算機問題引起的？

Joanne, I'm sorry, when you said the national data showing what? I didn't hear it.

喬安妮，對不起，您剛才說的全國數據顯示了什麼？我沒聽見。

Increase in wages.

工資增加。

Wages. Yes, wage like acceleration slightly, nothing material, obviously, but like just kind of versus the earlier in '24, and then somehow a couple of these last months in '24 kind of showed a little bit higher growth year-over-year. So I don't know if you're seeing any of that. I mean it sounds like you're thinking about kind of moderation in wage inflation for '25. I just want to ask that there was anything that happened in late '24 that kind of might have changed that view a little bit.

工資。是的，工資確實略有加速，但顯然沒有什麼實質性的，但與 2024 年早些時候相比，2024 年最後幾個月的同比增長似乎略有提高。所以我不知道你是否看到了這些。我的意思是，這聽起來好像你正在考慮在 25 年內緩和薪資通膨。我只是想問一下，24 年末發生的一些事情是否可能稍微改變這種觀點。

Yes. So again, clearly, we've seen a moderation in wage inflation coming out of the pandemic over the last couple of years. And I would sort of characterize the wage environment as fairly stable. I apologize, I didn't hear you the first time. But I think like you said, those -- the national survey sort of suggests kind of some incremental pressure on wages. I don't think we're really seeing that but doesn't mean that we won't. But it doesn't feel like there's that sort of comprehensive pressure and real significant pressure on wages that we were seeing a couple of years ago. It feels like the wage environment and basically the supply-demand environment for labor has stabilized pretty significantly.

是的。因此，很明顯，過去幾年疫情過後，我們看到薪資通膨有所緩和。我認為工資環境是相當穩定的。很抱歉，我第一次沒有聽清楚你說什麼。但我認為就像你說的，這些——全國調查在某種程度上表明工資面臨某種增量壓力。我認為我們實際上並沒有看到這一點，但這並不意味著我們不會看到這一點。但感覺我們並不像幾年前那樣面臨全面壓力和真正顯著的薪資壓力。感覺工資環境和勞動力的供需環境基本上已經相當穩定了。

And as we lessen our dependence on temporary labor, our wages overall continue to go down.

隨著我們減少對臨時工的依賴，我們的工資總體上繼續下降。

And if I may just squeeze in a last follow-up on the DPP discussion and how you assume '25 down versus '24. So two items there, right? Can you quantify how much was prior period that you recorded in '24? And also because we also said there are some programs that are expected to expect to decline. So is it based in those states, particularly those programs are based on enrollment and that's what's happening in some of the state is going to have a lower DPP dollars available to them because it's linked to enrollment?

如果我可以的話，最後再補充一下關於 DPP 的討論，以及您如何看待 25 年與 24 年相比有所下降。那麼那裡有兩件物品，對嗎？你能量化你在 24 年記錄的先前時期的數量嗎？而且我們也說過，有些項目預計會下降。那麼，它是否基於這些州，特別是那些基於入學率的項目，而這正是一些州的情況，由於與入學率有關，因此這些州可獲得的 DPP 資金會較少？

Yes. So I think if you go back and look at our transcripts from the first three quarters, in each quarter, we called out how much prior period there might have been. And it strikes to me that it was roughly sort of $15 million, $20 million a quarter, so you can extrapolate that. And it's maybe $60 million, $80 million of non-recurring or out-of-period items that we had in 2024. And as I said to kind of a previous question, I think that's the main driver.

是的。所以我認為，如果你回顧並查看我們前三個季度的成績單，我們會發現每個季度我們都會指出之前可能存在多少時期。我認為每季的收入大約是 1500 萬美元到 2000 萬美元，所以你可以推算。我們在 2024 年可能有 6,000 萬美元、8,000 萬美元的非經常性或期外計畫。正如我在回答之前的問題時所說的那樣，我認為這是主要驅動因素。

There may be some individual programs that are showing sort of slight declines next year. But for the most part, once programs have been established, our historical sort of experience says they stay at or if anything, they sort of grow. So again, I don't think that the slight decline in DPP for next year that we're forecasting is mostly driven by the out-of-period stuff we had in 2024 rather than any real declines in the programs in 2025.

一些個別項目明年可能會出現輕微下滑。但在大多數情況下，一旦專案建立起來，我們的歷史經驗表明，它們會保持不變，或有所發展。因此，我再說一遍，我認為我們預測的明年 DPP 的輕微下降主要不是由 2024 年的非同期因素所致，而是 2025 年專案的實際下降。

Stephen Baxter, Wells Fargo.

富國銀行的史蒂芬‧巴克斯特。

Just two quick ones. I was hoping to first -- I might have missed it, but sizing the full year amount that the medical mal process expense came in above your initial plan? And how much of that you assume normalizes and becomes a tailwind to the year-over-year EBITDA growth? And then just another follow-up on the DPP discussion. I understand fully, you're not including 2025 amounts for Tennessee or for Washington, D.C at this point, pending approval. But how do we think about what percentage of the DPP contribution that's in the guidance still for this year is tied to programs that do need to be renewed at some point this year? So might only have partial year coverage kind of as exists today.

只需簡單兩點。我首先希望——我可能錯過了，但如何估算出醫療事故處理費用高於您最初計劃的全年金額？您認為其中有多少會正常化並成為 EBITDA 同比增長的順風？然後再跟進 DPP 的討論。我完全理解，目前您還沒有包括田納西州或華盛頓特區的 2025 年金額，等待批准。但是，我們如何看待今年指導方針中的 DPP 貢獻中有多少比例與今年某個時候需要更新的項目掛鉤？因此可能只提供目前存在的部分年度覆蓋。

Yes. So as far as malpractice goes, what we said in our prepared remarks was we had $79 million of additional malpractice reserves that we added -- recorded above and beyond what we had in our original guidance. And for the most part, I think we don't believe that those expenses recur. And so that contributes to some of the growth that we have in 2025. We think we've been reasonably conservative. To be fair, that's a volatile area that can change and does change, but we feel like we've been fairly prudent and fairly conservative in general.

是的。因此，就醫療事故而言，我們在準備好的評論中說過，我們增加了 7900 萬美元的額外醫療事故準備金，超出了我們最初的指導金額。而且大多數情況下，我認為我們不相信這些費用會再次發生。這對我們在 2025 年實現的成長有所貢獻。我們認為我們已經相當保守了。公平地說，這是一個可能發生變化並且確實在發生變化的不穩定領域，但我們覺得總體而言我們相當謹慎和保守。

As far as your DPP question, I think as a previous question there indicated, we have a significant amount of disclosure about our DPP programs by state. And I'd refer everyone I know we filed the 10-K last night, so I'm sure people have had a chance to review it in detail. But we literally go through each program, indicate once being approved, what's not been approved. My guesstimate is that probably half of the DPP monies in our forecast roughly have been approved for next year already and probably half approval still pending.

就您提到的 DPP 問題，我想正如先前的問題所表明的那樣，我們按州披露了大量有關 DPP 計劃的資訊。我想告訴所有我認識的人，我們昨晚提交了 10-K 文件，因此我相信大家已經有機會詳細審查它了。但我們確實會仔細檢查每個項目，指出哪些項目已獲批准，哪些項目尚未獲批准。我估計，我們預測的 DPP 資金中大概有一半已經大致獲得明年的批准，還有一半仍有待批准。

Sarah James, Cantor Fitzgerald.

莎拉詹姆斯 (Sarah James)，費茲傑拉領唱者。

I wanted to go back to your strategy around the behavioral portfolio. Can you talk a little bit about areas that you're looking to expand? Are you guys looking at CPC or methadone clinics? Are you looking at more outpatient? Or is it really still focused on inpatient?

我想回顧一下你圍繞行為投資組合的策略。您能談談您想要擴展的領域嗎？你們是在尋找 CPC 還是美沙酮診所？您需要更多門診病人嗎？或者它實際上仍然專注於住院患者？

Yes. I mean I think we've said in previous calls, here, and I think this is true really of both segments, but specific to the behavioral business. I think we're looking to build out our continuum of care, and I think either Marc has mentioned that in our prepared remarks, which I think in behavioral specifically means building out the outpatient continuum. And I think that's reflective of -- historically building out the outpatient continuum generally mean on our campuses and sort of related to our inpatient programs. So patients who were discharged as inpatients often require continued follow-up care and often receive that care in our intensive outpatient or partial hospitalization programs.

是的。我的意思是，我認為我們在之前的電話會議中已經說過了，我認為這對於兩個部分來說都是如此，但具體到行為業務而言。我認為我們正在尋求建立我們的連續護理，我認為馬克在我們準備好的評論中提到了這一點，我認為在行為上具體意味著建立門診連續護理。我認為這反映了歷史上建立門診連續體通常意味著在我們的校園內，並且與我們的住院計劃有關。因此，出院的住院患者通常需要持續的後續護理，並且通常在我們的密集門診或部分住院計劃中接受護理。

I think we've started to develop more of a presence in freestanding outpatient facilities around the country. We acknowledge that some people who are receiving outpatient care don't necessarily feel comfortable receiving it on the campus of an inpatient hospital or affiliated with an inpatient hospital. And so we're finding that there is demand for freestanding outpatient care separate and apart from our hospitals. We continue to build out our outpatient capabilities as it relates to both active military and retired military. We have a real specialization in that.

我認為我們已經開始在全國各地的獨立門診設施中擴大影響力。我們承認，有些接受門診治療的人不一定願意在住院或住院醫院接受治療。因此我們發現，對於獨立於醫院的門診護理有需求。我們將繼續加強與現役軍人和退伍軍人相關的門診治療能力。我們在這方面擁有真正的專業知識。

We have begun, and again, I think we've talked about this in previous calls, to establish a little bit more of a presence in the opioid disorder space. I think we are tending to do so again, more as sort of part of a broader continuum of care rather than just sort of flat out medically assisted treatment facilities that are just dispensing medication. I think we feel like given our presence in such a broad continuum, our real ability to provide a competitive or clinical advantage is being able to provide patients with sort of a whole continuum of care, not just medically assisted treatment, whether that's methadone or Suboxone or whatever. But outpatient treatment, et cetera, inpatient treatment if that's required, et cetera. And so to the degree that we're entering or expanding our presence in that opioid space, I think it will be in that context of integrating with our broader continuum of care.

我們已經開始，而且我想我們在之前的電話會議中已經討論過這個問題，以便在阿片類藥物障礙領域建立更多的存在。我認為我們再次傾向於這樣做，更多地將其作為更廣泛的連續護理的一部分，而不僅僅是分發藥物的那種簡單的醫療輔助治療設施。我認為，鑑於我們在如此廣泛的領域中的存在，我們提供競爭或臨床優勢的真正能力是能夠為患者提供一系列的護理，而不僅僅是醫療輔助治療，無論是美沙酮還是丁丙諾啡等等。但是門診治療等等，如果需要的話，還有住院治療等等。因此，就我們進入或擴大阿片類藥物領域的程度而言，我認為這將與我們更廣泛的護理範圍相結合。

Great. And can you give us an idea of timeline to materiality of that, so what does the pipeline look like or how fast do you expect those businesses to grow?

偉大的。您能否向我們介紹一下實現這一目標的時間表，渠道是什麼樣的，或者您預計這些業務的成長速度有多快？

Yes. I mean, so again, I would make the point that we have a significant outpatient presence currently, mostly associated with our hospitals on our hospital campuses. The freestanding sort of efforts, I think, reasonably could result in probably 10 or so or a dozen or so additional facilities each year. The OUD space requires a bit more of a development pipeline. So I think a little bit harder to project that. But again, the point that I make there is I think that's likely to be integrated with some of our existing continuum, but a little bit harder to predict and a little bit slower to ramp.

是的。我的意思是，我再次強調，我們目前有大量門診病人，主要與我們醫院園區內的醫院有關。我認為，這種獨立的努力每年大概可以帶來 10 或十幾個額外的設施。OUD 領域需要更多的開發管道。因此我認為這項預測有點困難。但是，我再次指出的是，我認為這可能會與我們現有的一些連續體結合，但會更難預測一些，而且發展速度會更慢一些。

A.J. Rice, UBS.

A.J.賴斯、瑞銀。

I appreciate, Steve, that you guys are the -- really the only one that's made comments about what it might mean if the exchange enhanced subsidies were to go away in '26, I think you put about a $50 million headwind on that. Can you just -- since you're the only one that's really done that, can you just flush out some of the key assumptions you've got in coming up with that number? And how much variability you think there might be around that? Or is that -- you have a pretty good target on that?

史蒂夫，我很感激你們——實際上是唯一一個對如果交易所增強補貼在 26 年消失會意味著什麼發表評論的人，我認為你們對此造成了約 5000 萬美元的阻力。你能不能－因為你是唯一一個真正這樣做的人，你能不能明確一下你在得出這個數字時所做的一些關鍵假設？您認為這範圍內的變異性有多大？還是——您對此有一個非常好的目標？

Yes. So we made those comments or I made those comments back in the fall. And honestly, A.J., because I think people were generally overestimating the impact that we might have, if the subsidies, the exchange subsidies were to go away, which I don't believe is a certainty in any event at the moment. But -- and I made the point when I -- when we floated that estimate that it was very much a guestimate. It's really based on some pretty high-level assumptions. About 5% of our acute admissions are exchange covered patients right now.

是的。所以，我們或者說我在秋天就發表了那些評論。老實說，A.J.，因為我認為人們普遍高估了我們可能產生的影響，如果補貼、交易所補貼消失，我認為目前這還不是確定的。但是 — — 當我們提出這個估計時，我就指出了這一點，這在很大程度上只是一個估計。它確實是基於一些相當高級的假設。目前，我們約有 5% 的急症入院患者是交換覆蓋的患者。

We assumed that about half of those folks would lose their coverage if the subsidies went away. Now again, there's a lot of nuances that go along with that, some might be able to get other coverage, some might qualify for Medicaid interstate, et cetera. But we assume about half of those folks would lose their coverage. We would lose the elective business that those folks were bringing to our hospitals now, and we presume they would still come to our hospitals for their emergency coverage. And obviously, we wouldn't be reimbursed for that.

我們估計，一旦取消補貼，大約一半的人將失去保障。現在，再次強調，這其中還有很多細微差別，有些人可能能夠獲得其他保險，有些人可能有資格享受州際醫療補助，等等。但我們估計其中大約有一半的人將失去保險。我們將失去這些人現在為我們醫院帶來的選擇性業務，我們推測他們仍然會來我們醫院接受緊急治療。顯然，我們不會因此得到補償。

And so that's the kind of the basis of the assumptions that we made. So the other point I think that we made is this is, I think, largely in acute care dynamics. We don't separately track the number of exchange patients we have on the behavioral side in large part, we don't think it's quite as significant. And I think that's historically been because so many of these exchange products have very high copays and deductibles that are often not relevant to providing coverage in a behavioral hospital where they're likely to incur a much smaller build than they would in acute hospitals.

這就是我們做出這些假設的基礎。所以我認為我們提出的另一點是，這主要體現在急性護理動態上。我們並沒有單獨追蹤行為方面的交換患者數量，我們認為這並不那麼重要。我認為，從歷史上看，這是因為許多此類交換產品的共付額和免賠額都非常高，而這通常與行為醫院的保險無關，在行為醫院中，它們產生的保險費可能比在急性醫院中少得多。

Okay. All right. I just want to ask maybe two aspects of the guidance. I want to see how they -- if they're reflected in there. I think you've got some insurance revenue step up in '25. Can you just comment on that? And is that our top line dynamic that doesn't affect the operating income and so on?

好的。好的。我只是想問一下有關指導的兩個面向。我想看看它們如何——它們是否反映在那裡。我認為 25 年的保險收入會增加。您能對此發表評論嗎？我們的營收動態是否不會影響營業收入等？

And then the second thing I was going to ask about in the guidance is you opened West Henderson in Las Vegas late last year. You've got, I believe, a DC hospital that you're opening this spring. Have you -- do you think those are going to have much impact on consolidated revenue and EBITDA? And how about on the same-store numbers because those are two big markets, do they draw away from your existing facilities enough to impact the same-store trends?

然後，我想在指南中問的第二件事是，您在去年年底在拉斯維加斯開設了 West Henderson。我相信，你們今年春天將會在華盛頓特區開設醫院。您認為這些會對合併收入和 EBITDA 產生很大影響嗎？那麼同店銷售如何呢？因為這兩個市場很大，它們對您現有設施的吸引力是否足以影響同店銷售趨勢？

Yes. So as far as your first question about insurance revenue, a number of people, I think, sort of noted that the revenue guidance that we issued last night is sort of above the mid-single digits that I've talked about on this call. And I think your question addresses that. There's probably an assumption of about a $200 million increase in the revenues at our insurance subsidiaries. So that affects that top line as we've sort of discussed historically, our insurance subsidiary tends to operate at something pretty close to breakeven. So it's reflective on the revenue line, but not really reflected in a significant way [on either deadline].

是的。關於您關於保險收入的第一個問題，我想很多人都注意到，我們昨晚發布的收入預期略高於我在這次電話會議上談到的中等個位數。我想你的問題已經回答了這個問題。可能預計我們的保險子公司的收入將增加約 2 億美元。所以這會影響到營業收入，正如我們在歷史上討論過的，我們的保險子公司的營運往往接近盈虧平衡。因此，這反映在收入線上，但並沒有真正顯著地反映出來[在任一截止日期]。

As far as your second question about the two hospital openings, we mentioned in our prepared remarks that we expect that the combination of West Henderson in Vegas and Cedar Hill in Washington, DC will be EBITDA positive. I will note, and this will be a cosmetic thing, that as we look at same-store admissions and same store revenues and even same-store earnings, that will be a little bit, I think, distorting in our next year's numbers because both facilities are opening in markets where we have an existing presence. And so there'll probably be some cannibalization of our existing business.

關於您關於兩家醫院開業的第二個問題，我們在準備好的評論中提到，我們預計拉斯維加斯的 West Henderson 和華盛頓特區的 Cedar Hill 合併將產生正的 EBITDA。我要指出的是，這只是一個表面現象，當我們查看同店入場人數、同店收入甚至同店盈利時，我認為這會對我們明年的數據產生一點扭曲，因為這兩家門市都是在我們已有業務的市場開設的。因此，我們的現有業務可能會受到一定程度的蠶食。

I think it will make our same-store numbers look a little bit depressed, particularly admission numbers. But I think overall, West Henderson have gotten off to a very fast start as has been our experience when we opened hospitals in Las Vegas. We're expecting Cedar Hill to get off to a solid start as well. So either hospital shouldn't be much of a drag on earnings in 2025.

我認為這會讓我們的同店銷售額看起來有些低迷，尤其是入場人數。但我認為總體而言，西亨德森的起步非常快，就像我們在拉斯維加斯開設醫院時的經驗一樣。我們期待 Cedar Hill 也能有一個好的開局。因此，這兩家醫院在 2025 年的獲利表現都不會受到太大影響。

Michael Ha, Baird.

麥可·哈，貝爾德。

Two quick ones to start. Just to confirm on DPP for Tennessee and D.C is the total current, I guess, payment upside, $169 million across those two? And what do you typically recognize in terms of the flow through down into earnings on DPP?

首先快速開始兩個。只是為了確認田納西州和華盛頓特區的 DPP 目前總的支付上漲額是否為 1.69 億美元？就 DPP 的收益流入而言，您通常會認清什麼？

Yes. So Michael, I don't have our 10-K right in front of us, but that number sounds reasonably close, but people can validate that. We disclose the numbers on both our expected benefit from both those programs in the 10-K. And as to your second question, we generally have the view because we disclosed our -- all of our DPP numbers disclose our net numbers that is net of the provider tax. So we assume those numbers generally drop to the bottom line.

是的。所以邁克爾，我面前並沒有我們的 10-K，但是這個數字聽起來相當接近，但人們可以驗證這一點。我們在 10-K 報告中揭露了我們從這兩個項目預期獲得的收益數字。至於您的第二個問題，我們通常持有這種觀點，因為我們披露了——我們所有的 DPP 數字都披露了扣除提供者稅後的淨數字。因此我們假設這些數字通常會下降到底線。

Obviously, we make the point all the time that those reimbursements are really meant to provide for frankly, what's been inadequate Medicaid reimbursement for many years. So the immediate impact is a significant boost to our earnings but it's really making up in our minds for deficient earnings in the past.

顯然，我們一直強調，這些補償其實是為了彌補多年來醫療補助補償不足的問題。因此，直接的影響是我們的收益顯著增加，但這實際上彌補了我們過去的收益不足。

Got it. And then maybe a quick one and then another longer one for flu season. I don't -- I haven't heard you mention it. We're seeing one of the strongest in recent history. Any impact on 1Q?

知道了。然後可能要花一個短時間，然後再花一個較長時間，以應對流感季節。我沒有——我沒有聽過你提起這件事。我們正在經歷近代史上最嚴重的衰退。對第一季有影響嗎？

And then my real question would be just return to historical margins, you're there in behavioral a lot quicker than I think everyone expected. Looks like acute margin really the next phase and the embedded margin improvement seems quite powerful. I guess, at this kind of pace of margin improvement over the past year, would it'd be fair to say you might only be about a year or two away from getting back to those pre-Covid levels?

然後我真正的問題就是回到歷史邊際，你的行為變化比我以為大家預期的要快得多。看起來銳利利潤確實是下一階段，而且嵌入式利潤的改善看起來相當強大。我想，以過去一年利潤率提高的速度，是否可以公平地說，您可能只需要一兩年的時間就能恢復到新冠疫情之前的水平？

And then what does that path look like? What needs to happen operationally for that to materialize? Is it more like a return to normative patient mix levels or other efforts, initiatives seems like? Any comments there would be great.

那麼那條路徑是什麼樣的呢？為了實現這一目標，在營運上需要做些什麼？這是否更像是恢復到規範的患者組合水準或其他努力、舉措？任何評論都非常感謝。

So as to your question about the flu season, I think what we found is the flu season, which started earlier than usual for us in 2024 -- excuse me, in 2023, started later in 2024, although seemed to be more intense once it got going. Overall, I think when we look at our respiratory cases for the fourth quarter, not altogether different in 2024 than they were in 2023. To your point, I think the flu season and the busy flu season has continued into the first quarter. I think generally, we always have the view that a busy flu season or frankly not a busy flu season tends not to have a really significant impact on earnings.

至於您關於流感季節的問題，我認為我們發現，2024 年的流感季節比往常要早——對不起，2023 年是這樣的——但 2024 年開始得比較晚，儘管一旦開始似乎會更加激烈。總體而言，我認為當我們回顧第四季度的呼吸道病例時，2024 年與 2023 年並沒有什麼不同。正如您所說，我認為流感季節和流感高峰期已經持續到第一季。我認為一般來說，我們始終認為，繁忙的流感季節或坦白說不是繁忙的流感季節往往不會對收入產生真正重大的影響。

Flu and respiratory cases tend to not be the most profitable cases that we have. So overall, I think when we look back on annual results, we tend not to. I think site -- a busy flu season or a non-busy flu season is something that moves the needle in a significant way, although we acknowledge that there are -- that volumes have been impacted, particularly what will be impacted in Q1 by the busy flu season.

流感和呼吸道病例往往不是我們最賺錢的病例。因此總的來說，我認為當我們回顧年度業績時，我們傾向於不這樣做。我認為，流感季節的繁忙或非繁忙都會對情況產生重大影響，儘管我們承認，銷售已經受到了影響，尤其是流感季節繁忙對第一季的影響。

As far as your margin question goes, I think mainly directed towards the acute hospitals, we've mentioned before, I think that there are some structural hurdles that make it difficult for the acute business to necessarily return to pre-COVID margins. Things like the significant increase, like 150 basis point increase in physician expenses that we experienced mostly in 2023, the continued shift of profitable procedural and surgical business from inpatient to outpatient.

就您的利潤率問題而言，我認為主要針對的是急診醫院，我們之前提到過，我認為存在一些結構性障礙，使得急診業務很難恢復到疫情之前的利潤率。例如我們在 2023 年經歷的大幅成長，例如醫生費用增加了 150 個基點，獲利的手術和外科業務繼續從住院轉移到門診。

But generally, our margins have been improving in that business. And I think we'll continue to improve, like you said, over the next couple of years, whether or not during that period, we can get all the way back to pre-COVID margins. I'm not sure -- I'm not certain about that. I think to your point, we've gotten there on the behavioral side. I think we'll continue to grow those. And so as a result, I think we will get back to consolidated pre-COVID margins over the course of the next couple of years.

但總體而言，我們該業務的利潤率一直在提高。而且我認為，就像你說的，未來幾年我們會繼續改善，無論在此期間我們是否能夠完全恢復到疫情之前的利潤率。我不確定——我對此並不確定。我認為正如你所說，我們在行為方面已經取得了進展。我認為我們會繼續發展這些。因此，我認為我們將在未來幾年內恢復到疫情之前的綜合利潤率。

Benjamin Rossi, J.P. Morgan.

摩根大通的班傑明‧羅西。

Just on premium pay, you mentioned premium paid about $60 million coming in flat quarter-over-quarter versus your previous goal of exiting the year at about $50 million a quarter. Is that more opportunistic usage to manage throughput during 4Q? And then with acute volumes mattering a bit for '25, where do you see premium pay leveling out in this coming year?

僅就保險費支付而言，您提到保險費支付約為 6,000 萬美元，與上一季持平，而您之前的目標是年底每季支付約 5,000 萬美元。這是否是第四季度管理吞吐量的更多機會性使用？那麼，由於 25 年的交易量有點大，您認為明年的加班費會趨於平穩嗎？

I think one of the challenges in terms of further reductions to premium pay is that one of the things that occurred during COVID was more and more nurses chose to work as temporary or traveling nurses, preferring the flexibility that came with those jobs. And some of those nurses have returned to full-time work in our hospitals. We'll certainly try and attract more. But I do think there has been kind of that structural shift and there are just more nurses who are wanting to and willing to work as temporary and traveling nurses.

我認為進一步降低保費的挑戰之一是，在疫情期間發生的一件事是，越來越多的護士選擇擔任臨時護士或巡迴護士，他們更喜歡這些工作帶來的靈活性。其中一些護士已返回我們醫院全職工作。我們肯定會盡力吸引更多的人。但我確實認為已經發生了某種結構性轉變，而且越來越多的護理師希望並且願意擔任臨時護理師和巡迴護理師。

So I think realistically, we made the comment in our prepared remarks that we've run at about that $60 million a quarter of premium tag for the last three quarters. Might we be able to tweak that a little bit lower? Sure, but I don't see really significant savings from driving that number a whole lot lower than where it is today.

因此我認為，從現實角度來看，我們在準備好的評論中表示，過去三個季度，我們的保費約為每季 6000 萬美元。我們能不能把它調低一點？當然，但我認為，如果將這個數字比現在低很多，並不會帶來真正顯著的節省。

Great color there. And then just a follow-up. I know it's early here, but had some conversation on tariffs and proposed reciprocal tariffs. Just curious how you're thinking about the potential impact of supply spend and maybe where your fixed pricing stands for your 2025 supply spend or where you have any other pricing buffers within your supply contracts?

那裡的色彩很美。然後只是後續行動。我知道現在還為時過早，但我們已就關稅和擬議的互惠關稅進行了一些討論。只是好奇您如何看待供應支出的潛在影響，以及您的固定定價代表了 2025 年的供應支出，或者您的供應合約中是否存在任何其他定價緩衝？

Yes. So the challenge about making any sort of terribly meaningful comments about the impact of tariffs on our results is twofold. One is really trying to figure out what the tariffs are going to be, what countries, what the rates of the tariffs are going to be. As you know, they've changed quite a bit just in the four or five weeks of the new administration.

是的。因此，對關稅對我們的業績的影響做出任何非常有意義的評論所面臨的挑戰是雙重的。人們真正想弄清楚的是關稅是多少、針對哪些國家、關稅稅率是多少。如你所知，新政府上任僅四、五週時間，他們就發生了很大變化。

The good news, I think, which you sort of alluded to in your question is that a great many of our supply contracts are multiyear contracts that essentially have pricing protection, so that the risk of tariffs or the risk of increased costs really fall on the manufacturer while those contracts are in place. So I think my sense, and we certainly didn't really provide for any significant impact on our supply expense in 2025 from the tariffs. And I think that's generally our point of view. It's entirely possible that, that changes depending on these dynamics. And as you suggested, retaliatory tariffs and that sort of thing. But we'd have to see how that plays out in sort of the real world before being able to quantify this in a more meaningful way.

我認為，您在問題中提到的好消息是，我們的許多供應合同都是多年期合同，本質上具有價格保護，因此在合同有效期內，關稅風險或成本增加風險實際上落在製造商身上。所以我認為，根據我的感覺，我們確實沒有真正考慮到關稅對我們 2025 年的供應費用的任何重大影響。我認為這就是我們的觀點。這完全有可能，它會根據這些動態而改變。正如您所說，還有報復性關稅之類的事情。但我們必須先觀察它在現實世界中如何發揮作用，然後才能以更有意義的方式量化這一點。

Scott Fidel, Stephens.

史考特菲德爾、史蒂芬斯。

First question, just can you give us just the split when looking at the net supplemental payments for 2024, the $1.016 billion, just what the split is between acute and BH from that? And then similarly with the projection for '25, whether that split seem similar or if there's any directional change around that?

第一個問題，您能否告訴我們，2024 年的淨補充支付（10.16 億美元）中的 Acute 和 BH 之間的分配情況如何？然後與 25 年的預測類似，這種分裂是否看起來相似或是否有任何方向性的變化？

Yes. I mean, honestly, I don't have it right in front of me, Scott. I think they're split relatively evenly between the two segments, but I can move back when you have to be more precise about that. And no, I don't think this split changes much in 2025. Again, as we've sort of talked about before, I think the 2025 assumption is that most of the programs kind of continue at their current level.

是的。我的意思是，老實說，史考特，我面前並沒有這個機會。我認為它們在兩個部分之間的分配相對均勻，但是當你必須對此更加精確時我可以移回。不，我認為這種分佈在 2025 年不會發生太大變化。再次，正如我們之前談到的，我認為 2025 年的假設是大多數項目將繼續保持目前的水平。

Okay. Got it. And then I just want to follow up. I know A.J had asked a bit about the increase in the insurance revenue. We were just looking at the CMS data this week. Looks like your MA plan actually had some healthy growth. So that seems to be a driver of that, probably not where I would see that getting to $200 million, though. So Steve, maybe if you could just walk us through, clearly, it does look like the MA piece is a driver of that. But maybe just sort of walk us through from a product perspective, what's building up to that $200 million?

好的。知道了。然後我只是想跟進一下。我知道 A.J 曾經問過一些有關保險收入增加的問題。我們本週剛剛查看了 CMS 數據。看起來您的 MA 計劃確實取得了一些健康的進展。所以這似乎是一個驅動因素，不過我可能還不會看到它達到 2 億美元。所以史蒂夫，如果你能向我們簡單介紹一下，很明顯，MA 部分似乎是推動這一現象的一個因素。但也許您可以從產品的角度向我們介紹一下，這 2 億美元是如何實現的？

So our subscriber population is split pretty evenly between MA patients and commercial patients. I think most of the growth next year is in the MA population, but we do have both MA patients and commercial patients. So we're just -- again, it's a relatively small plan. But as we continue to gain more experience in the half, establish a track record in the various markets where the plan operates, we're able to attract more patients, et cetera. So the $200 million, I think, is reflective of the amount of new subscribers that we have.

因此，我們的使用者群體在 MA 患者和商業患者之間分配得相當均勻。我認為明年的大部分增長來自馬薩諸塞州人口，但我們確實同時擁有馬薩諸塞州患者和商業患者。所以我們只是—再說一次，這是一個相對較小的計劃。但隨著我們在半年內繼續獲得更多經驗，在該計劃運營的各個市場建立業績記錄，我們能夠吸引更多的患者等等。所以我認為，2 億美元反映了我們新增用戶的數量。

Got it. If I could ask one quick question or last one. Just around accruals that you have on the balance sheet, legal accruals for behavioral litigation. Just any updates on sort of where you ended the year on that and sort of how that may have sort of evolved in terms of any assumptions there?

知道了。如果我可以問一個簡單的問題或最後一個問題。圍繞資產負債表上的應計項目，還有行為訴訟的合法應計項目。您能就今年年底的情況以及根據哪些假設可能發生了哪些變化提供任何更新嗎？

Yes. So again, I mean, in the legal section of our 10-K, we describe the status of the two large malpractice cases and malpractice verdicts that we had in 2024. I suggest people can read through those. We don't have specific reserves established for those cases. They're both going through an appeal process and significant. Obviously, as I said earlier, when our third-party actuary goes through their exercise, they are taking into account all of cases, decided cases, pending cases, appeal cases, et cetera, as well as cases that have not reached that level and they're putting a value on cases that incurred or not yet, sort of been filed that sort of thing. So all that, I think, has been taken into account in the actuarial calculations.

是的。所以，我的意思是，在我們的 10-K 的法律部分，我們描述了 2024 年兩起大型醫療事故案件和醫療事故判決的情況。我建議大家可​​以讀這些內容。我們沒有針對這些情況設立專門的儲備金。他們都正在經歷上訴程序，而且意義重大。顯然，正如我之前所說，當我們的第三方精算師進行他們的工作時，他們會考慮所有的案件，已經判決的案件，未決的案件，上訴的案件等等，以及尚未達到那個級別的案件，並且他們會對已經發生或尚未提起的案件進行估價。所以我認為，所有這些都已在精算計算中考慮到了。

Ryan Langston, TD Cowen.

瑞安·蘭斯頓（Ryan Langston），TD Cowen。

The SWB performance in behavioral was the strongest, I think, in actually quite some time. Can you maybe just update us on the labor trends on BH, like if that was just related to specific facilities, geographies or job classes? And I guess how does if at all, the fourth quarter like inform the 2025 guidance?

我認為，實際上在相當長的一段時間內，行為中的 SWB 表現是最強的。您能否向我們介紹 BH 的勞動力趨勢，例如這是否僅與特定設施、地理位置或工作類別有關？我想問一下，如果有的話，第四季的數據將如何為 2025 年的指引提供參考？

Yes. I mean I think we have been saying for a number of quarters now that the labor supply demand dynamic within behavioral has clearly improved from the really significant pressures that we experienced during the pandemic. And so I think you're seeing a combination of things that are really sort of contributing to that strong performance. I think number one, productivity has been improving where we got the right number of people for the right number of patients to care for patients safely and providing top quality care. But we've also seen a moderation in the use of premium pay and outside temporary labor, and we've seen a moderation in wage inflation and all those things, I think, are contributing to the strong sort of productivity and efficiency performance that you've noted.

是的。我的意思是，我認為我們已經說了好幾個季度了，行為中的勞動供需動態已經明顯改善，擺脫了我們在疫情期間經歷的巨大壓力。所以我認為你看到了多種因素確實對這種強勁表現做出了貢獻。我認為，首先，生產力一直在提高，我們為適當數量的患者配備了適當數量的人力，以安全地照顧患者並提供最優質的護理。但我們也看到，使用額外工資和外部臨時工的情況有所緩和，工資通膨也有所緩和，我認為，所有這些都有助於提高你所指出的強勁的生產力和效率表現。

Got it. And then just piggybacking on the leverage and the share repo, just kind of where the shares are trading and kind of what's going on in the market? Like is there a potential that the repos for 2025 are maybe more front-loaded than maybe they have been in the sort of last couple of years?

知道了。然後只是藉助槓桿和股票回購，股票交易的地方以及市場上發生的事情是什麼？例如，2025 年的回購協議是否有可能比過去幾年更前期投入？

Yes. I mean, obviously, when you talk about what's going on in the markets, that changes day by day. So a little bit hard to make a judgment about exactly how the trajectory is going to look for the year, but it's certainly a consideration on our plan. What I would say historically is our share repurchases tend to be kind of more programmatic and ratable rather than really trying to time market changes, et cetera. I don't think we view ourselves as particularly good at market timing.

是的。我的意思是，顯然，當你談論市場正在發生的事情時，它每天都在改變。因此，很難判斷今年的發展軌跡究竟會如何，但這肯定是我們計劃中的一個考慮因素。從歷史上看，我想說的是，我們的股票回購往往更具程序性和可評級性，而不是真正試圖掌握市場變化的時機，等等。我認為我們不認為自己特別擅長把握市場時機。

What we do believe and what we try and take advantage of is the prospects of the business, we have a lot of confidence in the business and we're willing to invest in, if you will, buying back our own EBITDA, what we think are pretty attractive multiples. And I think that's the case now. And honestly, I think it's been the case and probably will be the case for some time. So I wouldn't commit to any particular sort of trajectory for this year. But as we have been for the past several years, I'm sure we will continue to be an active repurchaser.

我們確實相信並且試圖利用的是業務的前景，我們對業務非常有信心，並且我們願意投資，如果願意的話，回購我們自己的 EBITDA，我們認為這是非常有吸引力的倍數。我認為現在的情況就是這樣。老實說，我認為情況一直如此，而且可能還會持續一段時間。所以我不會對今年的任何特定軌跡做出承諾。但正如我們過去幾年所做的那樣，我相信我們將繼續成為一個積極的回購者。

Jamie Perse, Goldman Sachs.

高盛的傑米·珀斯 (Jamie Perse)。

Jamie, can I interrupt, but this is going to have to be our last question. We have another commitment after this.

傑米，我可以打斷一下嗎，但這是我們的最後一個問題。在此之後我們還有另一項承諾。

I guess just on commercial payors, what are you seeing in terms of payor activity and denials, prior authorization to midnight rule implementation, et cetera, and just sustainability of rate growth, particularly in the behavior it's been very strong?

我想僅就商業付款人而言，您在付款人活動和拒絕、午夜規則實施的事先授權等方面看到了什麼，以及利率增長的可持續性，特別是在行為非常強勁方面？

Yes. So I'll take the second part of your question first. I mean we've talked about this for some time now. We've had really strong behavioral pricing over the last several years. I think that's a function in large part of the scarcity of supply, supply of beds and care in the behavioral space. And as a consequence, we've been able to negotiate higher rates from many of our payors, payors who really are struggling to find a place for their subscribers to be treated, et cetera.

是的。所以我先回答你問題的第二部分。我的意思是我們已經討論這個問題有一段時間了。過去幾年來，我們的行為定價一直非常強勁。我認為這在很大程度上是由於行為空間中的供應、床位和護理的稀缺所造成的。因此，我們能夠與許多付款人協商更高的費率，這些付款人確實在努力為其訂戶找到接受治療的地方，等等。

I don't know that, that dynamic has changed a great deal. There's not a ton more particularly inpatient capacity, I think, in the space, et cetera. So again, I think the pricing environment for behavioral remains strong. As far as sort of payor behavior, I don't know that we would sort of suggest that there's been a significant change. I think this is a sort of a day-to-day issue with us. We find payor behavior broadly challenging, and it's kind of a daily struggle with us.

我不知道，這種動態已經發生了很大的變化。我認為，該空間的住院容量並不大，等等。因此，我再次認為行為的定價環境仍然強勁。就付款人行為而言，我不知道我們是否會認為發生了重大變化。我認為這是我們每天都會遇到的問題。我們發現付款人的行為普遍具有挑戰性，這對我們而言是一種日常鬥爭。

We've devoted a significant amount of resources to making sure that our claim submissions are as efficient and as clean as possible, then our appeals processes are as efficient and as clean as possible. It's been a huge focus of ours. And unfortunately, I think we'll have to remain that because I don't see payors all of a sudden becoming much more lax in their utilization review and denial management, et cetera. So it would be great if that dynamic were to change in our industry, but it doesn't seem to be something that's likely to change in the near term.

我們投入了大量的資源來確保我們的索賠提交盡可能高效和乾淨，我們的上訴流程盡可能高效和乾淨。這一直是我們關注的重點。不幸的是，我認為我們必須保持這種狀態，因為我沒有看到付款人突然在利用審查和拒絕管理等方面變得更加鬆懈。因此，如果我們行業的這種動態發生變化，那將是一件好事，但這似乎不太可能在短期內改變。

So operator, I think that's going to have to be the end of it for us. We'd like to thank everybody for their participation and look forward to talking with everybody after our first quarter results.

所以操作員，我想這對我們來說將是結束的時候了。我們感謝大家的參與，並期待在第一季業績公佈後與大家交流。

Thank you. Ladies and gentlemen, this does conclude today's presentation. You may now disconnect, and have a wonderful day.

謝謝。女士們、先生們，今天的演講到此結束。現在您可以斷開連接並享受美好的一天。