Universal Health Services, Inc. (UHS) on Q1 2021 Results - Earnings Call Transcript
Operator: Good day and thank you for standing by. Welcome to the First Quarter 2021 Earnings Conference Call. At this time all participants are in a listen only mode. After the speaker's presentation there'll be a question-and-answer session. I would now like to hand the conference over to your speaker today, Steve Felton, Chief Financial Officer. Please go ahead.
Steve Filton: Good morning. Marc Miller is also joining us this morning. We welcome you to this review of Universal Health Services Results for the First Quarter ended March 31, 2021. During the conference call, we will be using words such as believes, expects, anticipates, estimates and similar words that represent forecasts, projections and forward-looking statements.
Operator: Your first question is from Justin Lake with Wolfe Research. Your line is open.
Perry Wong: Yes, thanks. This is Perry Wong going in for Justin. My question is around pricing. It looks like your pricing was up about 26%, which is notably higher than your peers. I was wondering if you could give any color on what's driving that increase? Was it mostly due to a higher acuity from COVID cases? Or is there any benefit from better commercial mix there? Thanks.
Steve Filton: Sure. Well, obviously, we've seen during the entire pandemic, our pricing was above - well above historical levels. And the main driver of that has been the higher acuity of our COVID patient, to a lesser degree, our non-COVID patients as well. So I think some deferred care, et cetera, is driving higher pricing. I think our pricing and particularly, our acute care pricing in quarter one was particularly high for a number of reasons. In the fourth quarter, we talked about the fact that as a result of our IT event, our billing and collection activities were delayed. We saw an increased aging in our receivables, and that resulted in higher bad debt expense and lower net revenue based on our regular accounting conventions. We anticipated that we would recover some of that as we caught up on our billing and collection. And I think that did, in fact, occur in Q1, and I think we probably benefited to the tune of maybe $10 million or $15 million in that regard. I think that we also benefited from the presence of personal reimbursement. This is the government - the federal government's reimbursement of non-insured or uninsured patients with the COVID diagnosis, I think - which really there was very little of that in Q1 of last year, and that's another probably $15 million or $20 million.
Perry Wong: Okay. Thanks.
Operator: Your next question is from Kevin Fischbeck with Bank of America. Your line is open.
Kevin Fischbeck: Great. Thanks. I guess, maybe start off by asking how Q1 shaped up versus your internal expectations? I guess, it was a bit above the street, but it sounds like you're only reaffirming guidance even though you continue to expect things to progress well through the year. So just, I guess, how did Q1 shape up? And then are there any mitigating factors or things you're watching as the year goes on?
Steve Filton: Sure. So Kevin, I did actually say in my prepared remarks that the Q1 results were just slightly ahead of our internal forecast, which is partly why we've chosen not to make any changes to guidance, we feel like we're largely on track. The things that we're watching are the obvious things. We assume that as the year progresses, and this is what our guidance assumed as well that COVID volumes will continue to decline. Non-COVID volumes in both business segments will continue to recover. And also, I think, quite importantly, labor pressures will ease, and those pressures will be manifested in lower wage rate increases, as well as the ability to treat more patients, particularly on the payroll side.
Kevin Fischbeck: And then, I guess, just a follow-up there. As we think about that volume returning back to normal, I guess it's one of the things that we're hearing conflicting information from it seems like the hospital companies generally expect labor pressure to ease. But I guess some of the staffing companies continue to expect labor shortfalls, et cetera, as volumes return, putting upward pressure on demand there, and we see nurses potentially, look to leave the workforce. I guess, how are you thinking about margins on that volume as it returns back to normal, you normally think about lower acuity volume be coming in lower margins and then that wouldn't take on the labor side?
Steve Filton: Yeah, look, I think, Kevin, that the notion is that the things that have driven the pressure on both our wage rates and just on the overall availability of mostly clinical, but in some cases, non-clinical personnel are things like the actual virus itself. During the last 12, 13 months, at any point in time, we've had employees who are sidelined either with the virus itself or because they are being quarantined, because of exposure to the virus.
Kevin Fischbeck: All right. That's helpful. Thanks.
Operator: Your next question is from Ralph Giacobbe with Citi. Your line is open.
Ralph Giacobbe: Great. Thanks. Good morning. Steve, any weather impact to call out in the quarter? And maybe if you could just give a sense of how you exited March, and if you're willing to just discuss early trends you've seen so far in April?
Steve Filton: Yeah. So I talked about the COVID trends in my prepared remarks, Ralph, saying that in almost all of our hospitals, volume of COVID patients peaked in the first half of January and continued to level-off as the quarter went on. And then I would say kind of, late February, early March, we started to see measurable recovery, particularly in the acute business in elective and schedule procedural volumes. I think the good news about the weather is while it certainly had an impact in a broad geographic swath of our markets that included Texas and Oklahoma and Arkansas and Tennessee. Because it occurred largely, I think, in the middle of the quarter, and because I think it was so widespread, it's not like we were really losing market share to competitors during that time, I think people were just staying home or stuck at home. And I think because they had four or six weeks to recoup whatever procedures they had missed. I think by the end of the quarter, the impact was not really significant. So at the end of the day for, I think, both the reason of the COVID - decline in COVID volumes and the recovery from the weather events, clearly, March was you know, we exited the quarter in March a lot more profitably than we began the quarter in January.
Ralph Giacobbe: Okay. All right.
Steve Filton: I am sorry, and I would say those trends have continued into April as well.
Ralph Giacobbe: Okay. Got it. That's helpful. And then just on the guidance, obviously, you're reaffirming, you've talked about the cadence of earnings improving sort of as you move through the year, generally sort of sounds like in line with your initial expectation. But what about sequestration, can you size the benefit of that? And why doesn't that flow through the number or are there offsets any help there?
Steve Filton: Sure. It's a good question, and I think it was asked on the fourth quarter call as well. And I think what we said at the time was, we really didn't make a specific assumption about sequestration in our budget forecast, because this year was so difficult to forecast in terms of volumes and acuity and how they would both kind of trend as the year went on, et cetera. We were much more focused on those issues than we were on these specific reimbursement issues. So we have said that having the sequestration waiver extended is a benefit to us of $10 million or $11 million a quarter. But I wouldn't describe it as a pickup of $10 million or $11 million, per se, in our guidance. I would describe it more sort of accurately as a bit of a cushion in our guidance, because we didn't really make a specific assumption about it.
Ralph Giacobbe: Okay, all right. Fair enough. Thank you.
Operator: Your next question is from Josh Raskin with Nephron. Your line is open.
Unidentified Analyst: Hi, good morning. This is Marco on for Josh. Thanks for taking the questions. I just had a quick one. It seems like UHS is seeing a larger spread between admissions and adjusted admissions than some of its peers. So is there any reason why you aren't seeing those outpatient volumes coming back quicker? And did the weather events of the first quarter impact outpatient volumes differently than on the inpatient side? Thanks.
Steve Filton: Yeah. So I think - and we've talked about this in previous calls. I think the dynamic - the single dynamic that probably most separates our experience from our public and acute care hospital peers is the percentage proportionately of COVID patients that we've treated. We've talked in the last few quarters about the fact that something like the low to mid teens percentage of our admissions on the acute side have been COVID diagnosed patients. And I think our peers are either in the high single digits or maybe 8%, 9%, 10%. So that's a pretty significant difference.
Unidentified Analyst: All right. Thanks.
Operator: Your next question is from Jamie Perse with Goldman Sachs. Your line is open.
Jamie Perse: Hey. Good morning. Just first question on the quarter, I wanted to talk about COVID patients for a second. I know the question was asked a few times last year and basically, the response was that, COVID patients aren't very profitable. I'm wondering if that's changed at all, because you've had all these learnings over the last year. It's maybe a healthier patient population, lower length of stay, things like that. So can you comment on the impact of your COVID census in the quarter on revenue per adjusted admission and also the EBITDA impact?
Steve Filton: Yeah. So the point that we've made historically, and I would repeat because I think it's still valid is that medical patients in general are less profitable than surgical or procedural patients, COVID patients or medical patients. And therefore, I think that's equally true of them. The other issue is that COVID patients tend to be sicker. They're more acutely ill. They clearly have a longer length of stay than our regular medical patients, and that means that the costs associated with them are higher. To your point about, I think, kind of developing treatments and protocols, I do think that clinically, we and I think all hospitals have gotten more adept and more efficient at treating COVID patients over the last 12, 13, 14 months, as you might expect. I think we learned a lot about what the right things and the wrong things are to do. But unfortunately, a lot of those more efficient and better clinical treatments are also very expensive. So things like remdesivir, one of the main drugs that are being used to treat COVID patients are very expensive. And so, again, this dynamic of the profitability of COVID patients versus non-COVID patients, I think, still exists, that is COVID are simply less profitable than the surgical and procedural patients that they have generally crowded out during the pandemic.
Jamie Perse: Okay. That's helpful. And then just one on surgical volumes, I know you don't report those. But maybe you could comment on what you saw across the month of the quarter, both on the inpatient and outpatient surgical side. And any categories or sites of care that are recovering after or slower than others?
Steve Filton: Yeah. And again, I mean, I think what we have found and we have found this again throughout the entire pandemic period, is that as COVID volumes rise and they peak that our volumes of elective and scheduled procedures and non-COVID business tends to decline, and I think we certainly experienced that in Q1. So in the January time frame when COVID volumes were peaking, I would say that surgical and elective procedures were probably at 75% or 80% of pre-pandemic levels. I think by the end of the quarter, as COVID volumes have declined pretty measurably, we were at 95% plus of pre-pandemic elective and surgical volumes. And I think those trends have continued into April as well.
Steve Filton: All right. Thank you, Steve.
Operator: Our next question is from Frank Morgan with UHS . Your line is open.
Unidentified Analyst: Frank Morgan here. Yeah, I have a cost question. You talked about some of the severe labor pressure where people are chasing, working are chasing those rates. Is that more of an issue on the acute side or the behavioral side? And are there any particular markets where you see that as being worse? And I don't want to put words in your mouth, but is it fair to say that the limiting factor in behavioral health care is, in fact, still labor. The demand is higher than what you can serve given the labor pressure. And if that is true, do you - how do you balance just sacrificing margin to get that incremental revenue in that higher levels of top line? Thanks.
Steve Filton: Yeah. So I think, Frank, you accurately frame the question. We've talked about pressures on labor really from the beginning of the pandemic. And I think most of our hospital company peers have done as well. I'm not sure we're all experiencing it in the same markets and to the same degree, but I think it certainly is a macro issue. Interestingly, we have said throughout that the labor shortage has manifested itself differently in our two business segments. I think on the acute side, we certainly have seen an increase in wage rates themselves. We see an elevated usage of over time and shift differential and usage of temporary traveling nurses, all of which are measurably more expensive than our base wage rate for nurses and other clinical personnel. On the behavioral side, if you measure it by salaries and wages per adjusted patient day, which I think is the right way of measuring, you'll see that the cost of labor isn't going up all that much. The real challenge is we just simply can't pay enough to get sufficient personnel in at least some of our hospitals in some of our markets. And so I would say that on the behavioral side, and I think you alluded to this in your question, shortage of appropriate clinical and in some cases, non-clinical personnel are probably the single biggest obstacle and headwind to getting back to pre-pandemic volumes and quite frankly, even above pre-pandemic volumes. And I can assure you that it's probably the - I'm not saying probably, actually, I would say, most certainly, the single biggest focus of our operators as we turn our attention to what we need to do to both recruit and retain the proper amount of nurses, and that obviously includes proper pay rates that we're constantly doing, compensation surveys to make sure that we're remaining competitive. We're looking at our processes for recruiting and hiring and our processes for mentoring new nurses and new graduates, all those sort of things are a focus of ours. And we've made some progress. And I think as my earlier comments indicated, there's an expectation and then a hope that as the pandemic eases and the pressures of the pandemic ease, the labor pressures will ease as well and then some of the initiatives that we've been implementing will gain more traction.
Unidentified Analyst: Thank you.
Operator: Your next question is from Pito Chickering with Deutsche Bank. Your line is open.
Pito Chickering: Hey. Good morning, guys. Thanks for taking my questions. A question for Steve and Marc, if you want to jump in, if we step back a minute and look at the behavioral market, do you think that you guys are growing in line faster or slower than overall demand? And if slower, can you give us color on why you're growing slower and what should change during 2021?
Steve Filton: Marc, do you want to comment first?
Marc Miller: No, you can go ahead, Steve.
Steve Filton: Okay. So, Pito, I think my response to Frank, to some degree, he covers this, and I've said this before during the pandemic, every one of our internal data points and metrics indicates that volume continues to - or demand, I should say, continues to increase at least at pre-pandemic levels, if not in many cases, above pre-pandemic levels. So we measure that by the amount of incoming or inbound call traffic, telephone calls, Internet inquiries, et cetera. And I think there is also macro information out there that suggests that the number of diagnose behavioral illnesses have continued to increase, and there's been a lot written about the fact that mental health stress, et cetera, has been greater during the pandemic for a variety of reasons. And again, our biggest challenge throughout has really been our ability to satisfy that demand. And again, labor has probably been - labor shortages have probably been the single biggest impediment to doing that. Now that tends to be very geography specific, so that there are hospitals in which we do not have those issues, and we're seeing demand growing and volumes increasing. And then there are markets and geographies where we clearly see that taking place. I think it's worth noting that in the markets where we tend to experience those problems, every, again, data point that we have suggests that our peers are experiencing those same issues in those geographies. So where we've had to cap or close beds because unavailability of clinical personnel, we know that there's evidence that our peers have had to do the same thing in those same geographies.
Marc Miller: And I would just add to what Steve said, we have been dealing with certain staffing issues for a while now. We are taking new and different actions to try to combat some of this with just improvement in some of our internal processes that we think, and we have confidence we'll have a different outcome for us going forward. So when the specific market eases up a little bit, we will be probably more ready maybe than we've been in the past to capitalize on that, by improving operationally, some of the things that we are doing to attract staff, keep staff and so on.
Pito Chickering: Okay. And then, two quick follow-ups on the premium labor comments that you've talked about. Can you help us quantify how much the impact of cost in the first quarter, looking at premium hours as a percent of all nursing hours? Where did it peak during 1Q? Where do you guys exit in March? And as you look to 2Q, is it fair to think about margins improving due to lower premium labor despite a reduction of the strong pricing seen in 1Q?
Steve Filton: Yeah. Pito, so I would say this. At the beginning of the quarter, the way we measure sort of the impact of the labor pressures on wage rates, as we measure the percentage of our nursing hours, in particular, that are being paid at premium rates, things like overtime and registry and traveling nurses, et cetera. And I would say, in the beginning of the quarter when our COVID volumes really peaked, the percentage of our nursing hours that were being paid at premium rates were in the low double digits, 10%, 11%, 12%, something like that. By the end of the quarter, I think those rates were maybe half of that. And while that doesn't necessarily - you know, a shift of 500 or 600 basis points doesn't seem huge, I think that it's worth making the point that, those premium hours are often being paid at two or three times the rate of our regular hours. So the changes in the number of hours don't have to be all that significant to really start to drive volume changes. So, to your last point, I think that we think that as those pressures ease and as the percentage of premium hours come down to more normalized historical levels, they should have a beneficial impact on our margins, because while I think our revenues will also come down, because acuity will come down, I think that the incremental rate pressure is greater than the decline in revenues that we would anticipate.
Pito Chickering: Okay. Great. And then my last quick question here. You talked about sort of monthly trends for acute. Can it be same for behavioral, how do patient days track sort of in January in the peak of the COVID surge, sort of how did exit March? And any comments on April? Thanks so much.
Steve Filton: Yeah. So, again, I think behavioral patient days were about roughly 4% below last year for the quarter. I think at the beginning of the quarter, when COVID volumes were at their highest, that was probably more like 6% or 7% down, and at the end of the quarter, more 2% or 3% down. And again, the expectation, it may not be a steady progression like that, but I think our expectation is, those volumes will continue to improve as the year progresses, both because the COVID pressures will ease, and on a related note, the labor pressures will ease as well.
Pito Chickering: And then one clarification on that, when you're saying exitings are down 2%, 3% sort of March and April. Is that on 2020, which the comps got very easy for obvious reasons? Or is that versus 2019? Thanks.
Steve Filton: Yeah. So when I say pre-pandemic, we generally are using 2019 as that pre-pandemic measure. So that's what I'm referring to.
Pito Chickering: Great. Thanks, guys.
Operator: Your next question is from A.J. Rice of Credit Suisse. Your line is open.
A.J. Rice: Hi, everybody. A couple of quick questions, hopefully. One, obviously, you are reinstating the share repurchase. And I know - I wondered on capital deployment elsewhere the M&A pipeline, both - it sounded like there might be a few things that you were looking at last quarter. Any update on whether those still remain in play? And it also there's been press reporting about some larger deals that private equity has on - that I would broadly describe as behavioral that might be in the market. Any - just any update on your thinking about whether there's likely to be meaningful M&A this year from your perspective?
Marc Miller: Yeah, I'll answer that, A.J. It's Marc. We continue to look at deals on both sides. I would not categorize it as likely because we're in the middle of a lot of this investigation. But there are, and it seems like there is a little bit more activity happening right now on both sides. So I'm always optimistic that we're going to hit on something, but hard to say likely at this point.
A.J. Rice: Okay. That's great. Thanks. Steve, you made an amount of comments about what's happening with labor and how that's a constraint on volume growth on the behavioral side. The other two metrics that have impacted pre-pandemic, the growth trends in behavioral have been sort of the pricing dynamics and also the length of stay pressures that have generally been driven by a Medicaid managed care. Can you give us your updated thoughts? You've been doing better on pricing. I don't know whether you think pricing like what you're seeing now will continue, but any thoughts about that? And then also where we are with the whole length of stay issue relative to Medicaid masked care?
Steve Filton: Yeah. So I mean, I think what we've said over the course of the last several quarters is that sort of pre-pandemic, I think our behavioral pricing was increasing, on average, at about a 2% to 3% rate based on revenue per adjusted day base. During the pandemic, that increase has been more like in the 5% or 6% range. I think some of that elevated level of pricing increase is due to a bit of an easing of pressure on the part of our managed care insurance payers. We're seeing fewer denials, less charity care during the pandemic. While we love if that behavior continued post-pandemic, I suspect that managed care behavior will become a little bit more aggressive as the pandemic eases. On the other hand, some of that increase, I think, is more permanent in that we've gotten - we've been, I think, much more focused and aggressive about obtaining increases from particularly from some of our managed Medicaid payers from whom we have not had increases in quite some time, et cetera. And obviously, those are more sustainable. So my gut is that once the pandemic eases some more that, that behavioral pricing increase will settle in somewhere in between the sort of two numbers that I gave before, maybe in that 3%, 4% range. So that will be a little bit higher than historical, but a little bit lower than where we've been running over the last several quarters. And I think the same is generally true of length of stay. We've not seen a lot more transition to managed Medicaid during the pandemic. I don't know that it was an appropriate time for states to make big changes in their Medicaid programs. But also, as I think we've disclosed before, the vast majority of our Medicaid patients, you know, certainly something like three quarters of them are already in managed Medicaid programs. So I don't think we think that the impact of incremental or additional patients migrating to managed Medicaid will be that significant in the future. And I think we made this point in late 2019 and early in 2020, in January and February of 2020, what I would call pre-pandemic, length of stay has been leveling off, labor shortages had been leveling off, et cetera. And then the pandemic hits in mid-March of 2020 and the bottom falls out. But I think we felt like we had made a lot of progress on those couple of issues prior to the pandemic really beginning to impact those.
A.J. Rice: Okay. Maybe one last very specific question. And this may be too granular tell me if you want to just take it up offline. But if I look at that corporate expense item, it was sort of 1consistent this year versus last year. But I noticed last year tended to drop off by about $20 million to $25 million in the second and third quarter. And it seemed like that was a bigger drop-off than you traditionally did pre-pandemic. Is there - should we look for something seasonal pattern more like last year, or is - was that somehow driven by what happened with the pandemic and therefore, maybe it doesn't have the seasonal drop that we saw last year, but it's more muted going forward?
Steve Filton: Yeah. So honestly, A.J., it's a question that you asked us yesterday, and we continue to look at it. I will tell you that I think potentially, probably the biggest swing factor may be our own health benefits, which, like everybody else, I mean, started pre-pandemic at a normal level and then drop down as people had deferred care and not nearly as much care and now are increasing back up to increasing. So we will look at that, I think, further and try and give people a better sense of how they should model it in the future. But it strikes us that, that's the biggest swing factor.
A.J. Rice: Okay. All right. Well, that's interesting, incremental. Thanks for that.
Steve Filton: Sure.
Operator: Your final question is from John Ransom with Raymond James. Your line is open.
John Ransom: Hey, good morning. One for Steve and one for Marc. Steve, just want to just get you to confirm some math, if you would, on all of the 2021 one-timers, including bad debt recovery, HRSA sequester and anything else that you think we should pull out as we think about our '22 comparison. So just, kind of, a total good guy EBITDA number would be great? And then for Marc, we know there's a big psych deal in the marketplace. They want a big price, something like three times revenue, it's a premium asset. So when you guys look at something like that and think about running your returns, how do you put that through the filter of analysis? Thanks.
Marc Miller: Do you want me to go on that, Steve?
Steve Filton: Sure.
Marc Miller: Okay. So when we're looking at any deal, I mean, you're mentioning one particular one. But when we look at any deal, it's fairly consistent as far as our approach goes. I mean, if we think that the possible acquisition has merit, we're, obviously, going to do our diligence to figure out pricing and what we're comfortable at. And there are a lot of factors that go into it, which I won't go into everything here. But certainly, an asset on the behavioral side, we would consider the markets where the seller is already doing business, and how that overlaps with our markets, and that will play a big part in determining how interested we are. So, same thing on the acute care side, if we see something on acute, we would actually probably be more interested if there were synergies in markets where we already play, as long as we didn't have FTC issues, because we could build up our markets a little more. It's different on the behavioral side. But that consideration is a big one for us. And then, obviously, the pricing and who else is in the market competing against us. So, we continue to look at a couple of different opportunities on the BH side, and when it all comes to fruition, we'll - you'll certainly know about that.
Steve Filton: And then I'll just very quickly recap the sort of extraordinary, for want of a better word, particularly acute care revenue items in the quarter. I think we quantify the IT event impact, that is the recovery and collection of our aged receivables from Q4 in the sort of $10 million to $15 million range, state and local COVID-related reimbursement in the $5 million to $10 million range and the HRSA reimbursement of non or uninsured COVID patients in the sort of $15 million to $20 million range. I think those are the items we're talking about…
John Ransom: No, I'm sorry. I got that. I was thinking for the full year, as we think about full year '21 I know the bad debt recovery won't recur, sequester goes away. Thanks. I was trying to get an annual number. I got the quarter number.
Steve Filton: Okay. I'm sorry. So, yes, the IT event really is a one-time thing. The state and local that reimbursement is difficult to project. And the HRSA money is at the moment, are sort of slated to go through the national emergency date, which I think is currently July. I think the administration has suggested that they anticipated going through the end of the year. But technically, at least at the moment, it only goes through July. So we'll have to see what that benefit is.
John Ransom: Okay. Thank you.
Steve Filton: Thank you.
Operator: We have no further questions at this time. I turn the call back to presenters for closing remarks.
Steve Filton: Okay. We just like to thank everybody for their time and look forward to speaking with everybody again next quarter.
Operator: This concludes today's conference call. You may now disconnect.
