Universal Health Services, Inc. (UHS) on Q3 2022 Results - Earnings Call Transcript
Operator: Good day and thank you for standing by. Welcome to the Third Quarter 2022 Universal Health Services Earnings Conference Call. And at this time, all participants are in a listen-only mode. After the speakers' presentation, there will be a question-and-answer session. Please be advised that today's conference may be recorded. I would like to hand the conference over to your speakers today, Steve Filton, Executive Vice President and CFO; and Marc Miller, President and CEO. Please go ahead.
Steve Filton: Thank you, Michelle. Good morning. We welcome you to this review of Universal Health Services' results for the third quarter, ended September 30, 2022. 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. For anyone not familiar with the risks and uncertainties inherent in those 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, 2021, and our Form 10-Q for the quarter-ended June 30, 2022. We'd like to highlight just a couple of developments and business trends before opening the call up to questions. As discussed in our press release last night, the company reported net income attributable to UHS per diluted share of $2.50 for the third quarter of 2022. After adjusting for the impact of the item reflected on the supplemental schedule, as included with the press release, our adjusted net income attributable to UHS per diluted share was $2.54 for the quarter-ended September 30, 2022.
Marc Miller: During the third quarter, we experienced a decrease in the number of patients with a COVID diagnosis treated in our hospitals as compared to the prior-year quarter. As a percentage of total admissions, COVID-diagnosed patients made up 16% of our admissions in the third quarter of 2021, but only 6% of our admissions in the third quarter of 2022. In our Acute segment, this declined in COVID patients resulted in reduced revenues due to the lower acuity and less of the incremental government reimbursement associated with COVID patients. While overall surgical volume tended to recover to pre-pandemic levels, there was a measurable shift from in-patient to outpatient, resulting in further overall revenue softness. And while we were able to continue to reduce the amount of premium pay in the quarter, which declined from $117 million in the second quarter to $81 million in the third quarter, there was insufficient revenue growth to offset the accelerated rate of wage increases and other inflationary pressures. The $25 million we received in quality incentive fund payments, in Texas, helped to narrow the gap, leading to an Acute EBITDA result in the quarter only slightly below our internal forecasts. At the same time, this decline in COVID activity allowed our Behavioral hospitals to continue to reduce their labor vacancies, resulting in a reduction of the capping of bed capacity. The effect of increased volumes combined with solid pricing increases largely offset higher labor costs, leading to a Behavioral EBITDA result in the quarter slightly below our internal forecasts.
Steve Filton: We also note that the third quarter included approximately $8 million of losses related to startup facilities and $4 million to $5 million of losses related to the impact of Hurricane Ian, in late September. For the nine months ended September 30, 2022, we've incurred approximately $45 million of losses in connection with the startup facilities. Our cash generated from operating activities was $221 million during the third quarter of 2022, as compared to $442 million during the same quarter in 2021. The decline was largely due to the timing of payroll disbursements, the opening of new facilities, and the timing of certain -- or the receipt of certain supplemental reimbursements. We spent $570 million on capital expenditures during the first nine months of 2022. In reaction to the earnings softness experienced this year, we reduced the pace of our capital expenditures by about 22% to -- or $165 million for the first nine months of the year. Similarly, although we moderated the trajectory of our share repurchases, we plan to continue to be an active acquirer of our own shares. For the full-year of 2022, we estimate that we will acquire approximately 80% of the numbers of shares projected in our original guidance. During the third quarter of 2022, we repurchased approximately 1.6 million shares at an aggregate cost of approximately $158 million. During the first nine months of 2022, we repurchased approximately $5.85 million share at an aggregate cost of approximately $704 million.
Marc Miller: Yesterday morning, we announced the appointment of Eddie Sim to Executive Vice President and President Acute Care Division, succeeding Marvin Pember, who has announced his intention to retire. Eddie, who brings nearly 30 years of healthcare and leaderships experience, most recently served as Chief Operating Officer at Centura Health, in Denver, Colorado, where he led the system's three operating groups, clinical delivery and shared services, with annual revenues of approximately $5 billion. In this role, he was responsible for supporting improved care coordination, operational and clinical excellence, and alignment across Centura's ecosystem of 19 facilities, and more than 250 clinics. Prior to joining Centura Health, Eddie served in senior leadership roles of increasing responsibility for 11 years, at Baptist Health in Jacksonville, Florida. As president of physician integration there, he was responsible for an employed physician network of 380 physicians, and a clinically integrated network with more than 900 physicians. As we look forward to Eddie joining the company, in early December, we thank Marvin for his 11 years of service to UHS. Under Marvin's leadership, our Acute Care Division has experienced robust growth and expansion in key markets, as well as achieved a significant number of industry accolades and public recognition for quality and service. Marvin will remain with the organization for a transition period following Eddie's start with us, on December 5. We are pleased to answer questions at this time.
Operator: Thank you. And our first question comes from the line of Kevin Fischbeck with Bank of America. Your line is open. Please go ahead.
Kevin Fischbeck: Great, thanks. I guess everyone's starting to look towards 2023. I don't know if you're provide any comment in that direction, that would be fantastic, if not, most of your peers have given us kind of one-time items in 2022 to level-set the base we should be thinking about when thinking about 2023. Can you help us on either side of that analysis?
Steve Filton: Sure, Kevin. You know, it has never been UHS' practice to give guidance for the following year until our fourth quarter earnings announcement in February. And we're not going to depart from that this year. I think we've been pretty clear about the non-recurring items in our financials for the year. I'll just sort of comment on the third quarter. The QIF, or Q-I-F reimbursement that we received in Texas, for $25 million that Marc mentioned in his opening remarks, we believe should be a recurring reimbursement item, which is why we did not suggest tossing it out of the third quarter consideration. Other than that, we've identified the startup losses; we've identified the impact of the hurricane, in theory, and they should not reoccur next year. And then finally, I know at least one of our peers described this DPP reimbursement, in Florida, another sort of special Medicaid program. We do not record any of those funds in Q3 of this year, although we expect to record something in the neighborhood about $30 million of those next quarter, in the fourth quarter, and a similar amount next year.
Kevin Fischbeck: Okay, that's helpful. Are you thinking about like the government PHE money as kind of a headwind next year or was that tied to COVID volumes and therefore not really necessarily something we should be backing out of this year's numbers?
Steve Filton: See, I think it's the latter, Kevin. I mean, those government programs that were meant to subsidize hospitals, whether it was HRSA or the 20% add-on or the sequestration waiver, all were designed to help hospitals deal with the higher acuity and higher expense of COVID patients. As there are fewer COVID patients I think there's less of a need for that. I think the real variable as we think about the Acute business is, particularly in 2022, as COVID volumes have declined, non-COVID volumes, electives and other procedures have been a little bit slower to recover and snap back than they were in 2021. I think we see them slowly coming back. And I think we think that will continue into 2023. But in my mind, the pace of that recovery is probably sort of the most important variable as we think about the performance of the Acute Division, in addition to the other prevalent item which, of course, is just the labor -- the tightness in the labor market.
Kevin Fischbeck: All right, great. Thank you.
Operator: Thank you. And our next question comes from the line of Ann Hynes with Mizuho Group. Your line is open. Please go ahead.
Ann Hynes: Hi, good morning. Maybe on 2022 guidance, you didn't mention in the press release. Is that still a good gauge for this year? And directionally, would you prefer consensus estimates to go to the low-to-mid range given the first three months? How should we think about that for Q4?
Steve Filton: Yes, and so I think, and consistent with our prior practice, as we don't mention guidance in the press release, we're affirming our previous issued guidance, which is what we're doing. I think, during the third quarter, and in some public appearances at conferences, et cetera, I think I conceded that the top end of the guidance was practically not a reasonable target. But I think we feel like as long as the trends that we saw in Q3 continue to a reasonable degree in Q4, some place in the lower half of guidance, it should be very achievable, especially with some of the non-recurring items, particularly the DPP moneys, in Florida, that I mentioned in my previous response.
Ann Hynes: All right. And just one follow-up question, I think you said in your prepared presentation that you're reducing your expectations for share repurchase by 20%. Can you just talk about the drivers of that, and how we should view this for next year, and also CapEx for next year? I mean, I know you've reduced your budget by 33%, is that just a wait-and-see or do you think that will continue into next year? Thanks.
Steve Filton: Yes, and so just to clarify what I said in the prepared remarks was our original guidance for the year presumed about $1.4 billion in share repurchases, obviously at a higher price than what we've been currently trading at. What I said is that we'd likely repurchase about 80% of the original number of shares. Probably from a dollar standpoint, that's more like 60%, $800 million-$850 million of the original $1.4 billion. Similarly, I think we've trimmed our CapEx forecast, from $1 billion originally, to something, again, more in like the $800 million range. In both cases, we've done that, I think, as out of an abundance of caution. Obviously, in an environment of rising interest rates and just on certain operating trends, we want to be appropriately cautious. We continue to believe that investing in our own EBITDA growth and our own earnings stream is still one of the most prudent investments we can make. So, I think we'll continue to be an active acquirer of shares into next year. We'll be much more specific about what our precise assumptions are when we give our guidance, in February. But I'd suggest it as people think about their models today, you think about CapEx and share repurchase in those sort of ranges of 2022, $800 million-some-odd for CapEx and $800 million-$850 million for share repurchase.
Ann Hynes: Great, thanks.
Operator: Thank you. And our next question comes from the line of Noah Comen with FactSet. Your line is open. Please go ahead. Noah, your line may be on mute. Okay, we'll go ahead and move to our next question. And our next question will come from the line of Austin Gerlach with Wolfe Research. Your line is open. Please go ahead.
Justin Lake: Hey, this is Justin Lake, at Wolfe. Thanks. A couple questions here, first on wages. Steve, obviously you guys did a great job of improving contract labor in the quarter. You're already kind of at your fourth quarter targets. So, one, do you expect that to continue moderating or does it stabilize here? And then to your point, a lot of appears to be offset by higher wage growth. Can you give us any color on what wage growth is doing for your permanent employees just so we can get an idea of how that's running in the next year?
Steve Filton: Yes, Justin. So, I think on the first question, yes, I think we intend and plan to further reduce premium pay. Premium pay was running about $35 million a quarter in the Acute segment pre-pandemic. I don't think it's realistic to get down to those levels, but I think it's not a stretch to say that we should still be able to get down maybe another $15 million-$20 million at least in the next quarter. To your second point, yes, I mean not all of that reduction sort of falls to the bottom line because some of the cost of reducing that premium pay is increased wages that we're having to pay to recruit and retain talent. I think we've said a number of times over the last several quarters that probably base wage rate inflation in both segments has been running, I'm going to say, 175 to 200 basis points higher than pre-pandemic levels. So, I think, if in Acute it was 3%-3.25% pre-pandemic, it's closer to 5% now. And in April, it was 2%-2.5% pre-pandemic, it's closer to 4%-4.25% now. I think one of the reasons that we're not prepared to talk about specific 2023 guidance is we'd like to see how those trends sort out over the next several months. I think we have a perspective that, given some of the inflationary and other economic pressures out there, that it may actually contribute to somewhat of a lessening of the pressure on wages, and maybe we'll see that number, probably not return to pre-pandemic levels the wage inflation number, but maybe somewhere between where we are today and pre-pandemic levels. But I think that's to be seen over the next several months.
Justin Lake: Got it. And you kind of already went to my second question on just inflation. One of your peers talked about inflation, and it seemed like they were talking beyond labor. Just curious, when you think about supply costs, for instance, professional fees, things outside of labor that could be impacted by inflation, are you seeing any kind of pivots there? Anything that's trending that we should think about into 2023? Thanks.
Steve Filton: Yes, I mean if you look at our income statement, clearly the biggest pressure is on the salary and wage line. But certainly we're experiencing inflation on an overall basis throughout our portfolio. As an example, utility costs, although it's a very small percentage of our overall costs, but they have clearly risen by significant numbers in many of our facilities. But again, that the key driver, I think, is wages as our focus is on, again, reducing premium pay, filling as many permanent vacancies as we can. And I think if we can do that, number one, that will drive higher volume growth which will help us offset some of this inflationary pressure.
Operator: Thank you. And we will move on to the next question. And our next question comes from the line of Jason Cassorla with Citi. Your line is open. Please go ahead.
Jason Cassorla: Great, thanks. Good morning. Just on your prepared remarks around the measurable shift in surgical volumes, the outpatient setting in the quarter, do you believe this move is a sustained construct moving forward, or would you call this as more of a onetime consideration and you would expect a reversion back to a more gradual shift over time?
Steve Filton: Jason, obviously in sort of the broader context for the industry this shift from inpatient settings to outpatient settings has been going on for an extended period of time certainly well over a decade. I think it accelerated during the pandemic. From a Behavioral perspective, people I think were in some cases more comfortable receiving care in settings outside of hospitals and hospital emergency rooms. We have seen that just as one example our free standing emergency department. We have about 25 of those today around the country. Have been extremely busy during the pandemic, and especially, I would say over the last six to 12 months. I think again for a variety of reasons people are just more comfortable receiving their care there. I think to a degree we will have sort of normalization back to a bit of a mean. People will return to the hospitals as we move further and further away from the concerns about COVID and COVID surges. But obviously there are other reasons why -- certainly the payors are taking advantage of this opportunity to continue to pressure more business to move to outpatient. And part of -- quite thankfully, we acknowledge all that. And we have been investing in outpatient development in both of our business segments for -- . I think the trend accelerated somewhat during the pandemic. But I think more broadly itâs just a continuation of a trend thatâs been in place for some time. And I think our business strategy in both of our businesses takes that into account, and we are very cognizant of that.
Jason Cassorla: Yes, okay, thanks. And then, just as a follow up here just as we think about the potential wind down of the COVID public health emergency early next year, you have talked in the past about some of the considerations on Medicaid re-determinations and on volumes, but I guess that the incremental dollars that is also rolled in the States are also coming to an end. I know itâs early, but I was wondering what your outlook is for Medicaid rates next year for both side of the business. And if you think there could be pressure there just given the ending of SMAP?
Steve Filton: Yes, I mean I think sort of mechanically the ending of SMAP probably creates some incremental headwind although I donât think itâs necessarily material. Again, I think at a sort of 20,000 foot level, itâs going to be difficult for our reimbursement especially from the government at the Medicare and Medicaid level to fully offset inflation. I think the way we are presuming that the biggest offset to these inflationary increases will be a return to pre-pandemic volumes, and quite frankly, volumes above and beyond pre-pandemic levels, because to be perfectly frank, I donât think that pricing can account or can offset all of the inflationary pressures that we are going to face.
Jason Cassorla: Got it. Okay, thanks for all the color.
Operator: Thank you and one moment for our next question. And our next question comes from the line of A.J. Rice with Credit Suisse. Your line is open. Please go ahead.
A. J. Rice: Thanks. Hi everybody. First may be just to ask you about the Behavioral trends in the quarter. Obviously, that bounces back very nicely. Strong -- revenue up 8% and good margin leverage, I assume some of that is because COVID crowded out some psych cases last year and you're just against an easy comp, but any updated thoughts on where we are at in terms of getting back to a normal growth cycle mid single digits or a little better even in the psych hospital businesses and the mix between revenue and volumes? I know historically sort of describe that as about equal 2% to 3% of age. But any updated thoughts on that, given the strong quarter?
Steve Filton: I think we have said a number of times during the pandemic, AJ, that our experience has been that during periods of higher COVID utilization, the Behavioral business has clearly struggled more than the Acute business, there's really no benefit to the Behavioral business, there's no increased acuity, there's no increased reimbursement, there's just the challenge of having to isolate COVID patients from the rest of the patient population, often resulting in some closed beds, et cetera. And then there's the pressure on labor. Whenever there's a COVID surge, we have more employees out sick, where even if it's only for a week or two, and it just creates more pressure in an already tight labor environment. So, I think what we experienced in Q3 is what we've experienced previously, like in the second quarter of 2021, in a period of relatively low COVID utilization, which is not nearly as many sort of patient matching problems, and the ability to fill more labor vacancies. And when we're able to do that, we're able to admit more patients. And we've talked about being able in a sort of post-COVID environment, or at least in an endemic environment, being able to achieve that mid-single-digit to upper single digit revenue growth, that we've been able to historically achieve pre-pandemic in the Behavioral business. And the third quarter, I think, was reflective of our ability to do that. The challenge is I don't know that we'll have a sort of straight line of that. We may see another COVID surge in the winter here. But I think as we've -- you said many times, we think the underlying demand for Behavioral services remains quite strong. And as long as we can continue to address and make progress on the labor issue, I think we're going to continue to see revenue growth that's more closely related to our historical trends.
A. J. Rice: Okay. And maybe just a question on the Acute side, if I look at some of the metrics length of stay showed a meaningful improvement that obviously is a favorable benefit for you. Any comment on what was going on there? And then some of the companies are talking about even if not year-over-year, because last year had a lot of COVID. Sequentially, they're starting to see stabilization and metrics like payer mix, and in revenue per adjusted admission, particularly on the commercial side was some a little bit of optimism around rate updates for next year. Any comment on any of those metrics that you would want to give?
Steve Filton: Yes, I mean I think as to the length of stay question is directly related to the metrics that Marc discussed in his opening remarks. Last year's quarter had 16% of our Acute patients is COVID diagnosed this year at 6%. The reduction in the number of those high acuity COVID patients, I think is sort of directly related to the length of stay decline. I would add that I think we believe that further reductions in length of stay are possible, and are actually maybe one of the most, if not the most significant opportunity, we have to be more efficient in control costs. For many of our patients, certainly for almost all of our government patients, and for even a significant chunk of our commercial patients, we're paid on a per admission basis. So, to the degree that there's an extra day or two of length of stay that is really unnecessary. We're just incurring additional costs without additional reimbursement. And we've struggled during the pandemic for a number of reasons, a lot of it has to do with the inability to refer patients to traditional subacute venues, because they're struggling with some of the same capacity issues we have, and other reasons, but we're very focused on the continued reduction in length of stay. As far as your other question, I don't think we've had a lot of volatility in payer mix during the pandemic. So, I would say it's probably as stable and then continues to be stable. Again I would say the same thing I've now said a number of times, I think what we look forward to, as more and more people just get accustomed to living and working and getting their healthcare in a COVID environment or an endemic environment, that more people will be comfortable seeing their physicians, getting a primary and specialty care that they've historically gotten and getting that care in hospital settings and hospital outpatient settings. And we think that that trend has started to manifest itself and will continue.
A. J. Rice: Okay. Thanks a lot.
Operator: Thank you. And our next question comes from the line of Andrew Mok with UBS. Your line is open. Please go ahead.
Andrew Mok: Hi, good morning. Wanted to follow-up on Justinâs labor question, Steve, I think you mentioned another $15 million to $20 million in potential improvement in the fourth quarter. Do you have visibility into that level of improvement today based on the current trend and anything else you would point to thatâs going to drive sequential EBITDA improvement in the fourth quarter? Thanks.
Steve Filton: All I would say Andrew is, weâve obviously had a significant amount of success in the Acute division in reducing premium pay. It peaked at about $150 million in Q1. It was $117 million in Q2, as Mark said, and then $81 million in this third quarter. So, weâve seen that trending down and believe that we can continue to propel that further reduction. Obviously, there is some sort of level of fixed amount of premium pay that is appropriate. I was saying, of a $35 million pre-pandemic. I donât think thatâs a realistic target at this point. But thatâs the basis on which we believe that we can continue to reduce that number. Itâs clearly a trend and it has not yet flattened out and I donât think it will.
Andrew Mok: Got it. Okay. As a follow-up, I think, Steve, you mentioned earlier this year that youâre starting to enhance your footprint in the Medicaid assisted treatment line. Can you update us on your progress there and how would you characterize the broader MAT opportunity over the next 18 months? Thanks.
Steve Filton: Yes. I mean, itâs a -- at the moment, itâs a relatively sort of fragmented process in the sense that really doing it kind of boots on the ground, developing some MAT facilities doing or pursuing some kind of small one, two, three off acquisition type areas. And I think as Iâve mentioned before we donât necessarily see this as a huge driver of growth in the future as much as we see it as really enhancing our very fulsome continuum of care in the Behavioral space. We treat virtually all diagnosis across inpatient, outpatient settings. And MAT was just sort of a gap in that. So, weâre going to continue to pursue the opportunity to do that at least in some of our markets. But itâs really much, much -- part of a much broader strategy of being one of the more comprehensive providers or maybe the most comprehensive provider of Behavioral services in the country.
Andrew Mok: Great. Thanks for the color.
Operator: Thank you. And our next question comes on the line of Stephen Baxter with Wells Fargo. Your line is open. Please go ahead.
Stephen Baxter: Yes. Hi, thanks for the question. Wanted to ask a follow-up on the pricing discussion earlier, I think you suggested that it might be challenging for your pricing yield to keep up with inflationary pressures, but just wanted to clarify that. Was that commentary specific to your government yield or your overall pricing yield? And I guess my actual question wouldâve been just wanted to get an update on your commercial rate negotiations for 2023. I guess what percentage of your commercial book will be in the first year of a new contract in 2023? And then what do you think the incremental yield would be compared to a typical update? Thank you.
Marc Miller: Yes. So, I think my previous comments clearly called out the fact that because half of our revenue comes from government sources and we know that theyâre simply not at the moment keeping up with inflation. Although, I think we believe that weâll continue to get incremental increases from those government sources over the next couple of years that that was probably the bigger challenge. I think on the commercial side of things, we continue to seek higher rates and more acknowledgement from our commercial payers that we need greater reimbursement to operate in this sort of inflationary environment. On the Behavioral side that overall pricing has been stronger -- were strong in the quarter. Weâve talked in previous calls about our relatively aggressive stance that weâve been taking with a number of payers in part because thatâs a business in which weâve been capacity constrained. So, it makes sense to us or for us to go to our lowest paying payers and either require them to come up to market levels of reimbursement or terminate those contracts. Because if weâre going to turn patients away, it makes sense to terminate those that are sort of the most inadequate, if you will, payers. On the Acute side, and again, this idea of sort of how many of our contracts have been renewed, et cetera. I think is a little bit outdated in the sense that virtually all of our managed care contracts have short-term out that most of them have 90 or 120 day out. So, weâre renegotiating contracts in both our Acute and Behavioral spaces where we think thereâs an opportunity, where we think that a payer may be under market, where we think that we might have an appropriate amount of leverage to press for greater rates, et cetera. So, yes, we will definitely get more relief on the pricing side, clearly on our commercial side of the business, and weâre aggressively seeking that. And again I was sort of describing the shortfall clearly as being more on the government side.
Operator: Thank you. And weâll go to our next question. And our next question comes from the line of Whit Mayo with SVB Securities. Your line is open. Please go ahead.
Whit Mayo: Thanks. Just wanted to follow-up on contract labor for just one second, Steve, how much of the improvement in the third quarter was utilization versus bill rates? And do you have an idea of what your exit rate was in the quarter? Iâve got you pegged at around 10% of Acute SWB in the quarter, but just wondering if that trended maybe a little bit more favorably towards the end of the quarter. Thanks.
Steve Filton: Yes. I mean I think and in my mind, this is sort of intuitive that the improvement in premium pay is a combination of both rate and utilization. Obviously, as the demand for those temporary and traveling nurses comes down, the rates that are required or being demanded for them comes down as well. So, I would say itâs a pretty even mix of rate and value coming down. I donât have the specific month by month premium pay numbers in front of me with, but as you know, I was sort of referring to in my -- in a previous response, I mean what we -- I think have seen is a steady incremental decline in premium pay since the beginning of the year when COVID volumes peaked. And so I think our exit rate in the quarter was certainly higher or how we going to view it a lower amount of premium pay or a greater reduction than it was in the beginning.
Whit Mayo: Okay. And do you have a number for the contract labor spin in the Behavioral segment? I know and recognize that itâs not as significant of a pain point, but just wanted to see if you had that.
Steve Filton: Yes. I mean I think historically itâs been about a third of what it is in the Acute side, but I donât have the specific number in front of me.
Whit Mayo: Okay. Well, one last one just corporate overhead, I know this number bounces around, but came in lower than sort of where we thought it might shake out. Just any developments or anything to call out would be helpful. Thanks.
Steve Filton: Yes. I donât think anything terribly specific. I will say that the decline in corporate overhead in Q3 of this year was pretty consistent with what we experienced last year, but as weâve analyzed those numbers, thereâs nothing terribly material driving that.
Whit Mayo: Okay. Thanks, guys.
Operator: Thank you. And our next question comes from the line of Gary Taylor with Cowen. Your line is open. Please go ahead.
Gary Taylor: Hi, good morning. Just a couple quick ones for me, it doesnât sound like on the hurricane any material impact expected to continue into the fourth quarter, that was just a disruption, but nothing damaging that would be continuing?
Marc Miller: Thatâs correct, Gary. We didnât suffer fortunately any significant physical damage in any of our facilities. So, I think all the impacts were temporary and most should be recovered in the fourth quarter.
Gary Taylor: And then on the Florida DPP for 4Q I know youâd mentioned that earlier in the year. I just want to make sure I understand a $30 million, is that the EBITDA impact or is there Iâm thinking of the other companies have had like a gross revenue number or a provider tax number associated with it, and then a net sort of EBITDA?
Steve Filton: Yes, so that $30 million is the EBITDA impact.
Gary Taylor: Okay. And then last one, when I look at modeling the Acute segment, the line that really is most challenging for me I am just struggling to stay up it and perhaps understand is that other operating expense line thatâs up almost $100 million year-over-year. I donât think there is any contract labor in there. I think itâs professional fees and utilities and insurance is like the most largest items cited in that bucket. Could you just maybe confirm that? And maybe just help us think about that up a $100 million year-over-year, what the two or three largest drivers of that are?
Steve Filton: Sure. So, clearly and we have talked about this on previous calls the most significant driver and I think the biggest distortion is the insurance subsidiary where we record our medical loss ratio in that line. And because the medical loss ratio for our insurance subsidiary like any insurance subsidiary is 85 or 90% of revenues. And otherwise, that other operating expense line for our hospitals is more something like 20% revenue. And to a degree that there is a revenue increase in the insurance subsidiary, it sort of distorts that line. So, in the third quarter, there is about $30 million to $40 million increase in insurance subsidiary revenues and expenses. If you adjust that out of other operating expenses, I think rather than like a 15% increase quarter-over-quarter itâs certainly like 10%. And I think thatâs probably a reasonable go-forward. I donât have the year-to-date numbers in front of me. But, we can certainly provide those. We will make a point I think when we give guidance for 2023 of trying to separate out the impact of the insurance subsidiary and those numbers. So, itâs easier for people to follow. I understand the difficulty that creates.
Gary Taylor: Yes. Steve, I have the three largest buckets of spend on the Acute other OpEx correct, when we think about professional fees, .
Steve Filton: Yes, I would say after adjusting out the insurance, there is a bunch of miscellaneous things. Probably the other most volatile item in the most recent past has been physician payment. So, our payments to physicians including locum physicians and increased subsidies for hospital-based physicians et cetera would be recorded on that line. And so you are seeing some impact of that, and then just the impact of broad general inflation.
Gary Taylor: Thanks.
Operator: Thank you. And one moment for our next question. And our next question comes from the line of Pito Chickering with Deutsche Bank. Your line is open. Please go ahead.
Pito Chickering: Yes, good morning, guys. Thanks for taking my questions. Three follow-up questions that is focused on Behavioral, number one, how did behavioral business track in September October? Is it fair to think about 3Q admission growth continuing in the fourth quarter? Number two, if 3Q margins Behavioral the right sort of run rate for the fourth quarter? And number three, thinking about 2023 behavioral if pricing is 4% to 5% range and wages in the low 4% range, is there any reason we should not think about margin improvement in Behavioral in 2023? Thanks so much.
Steve Filton: Yes, I mean -- look, I think we made these comments broadly. And I think most hospitals have made these comments broadly. July volumes in both Behavioral and Acute were really rather soft. August tracked better. And I think September was sort of a reflection of the two month -- the two earlier months combined. So, I think the trend is upward. But I think what we have learnt during the pandemic is the trends are a bit more volatile than they have been historically. But again, I think the thing that we say with some confidence is that in periods of lower COVID utilization, Behavioral volumes will tend to trend upward. And thatâs been our experience. As far as the sort of question about if we continue to have mid single digit and upper single revenue growth as we did in Q3, should that be enough to allow for margin improvement? I think the answer is yes. I mean I think we saw that in the quarter. And I donât think there is any reason why we shouldnât continue to see that going forward.
Pito Chickering: Whatâs the follow-up on the Acute wages, are you seeing your competitors sort of raise full-time employee wages multiple times during 2022, like it did in 2021? Or are we just generally all coming with same levels and, hence, why you think the wage inflation in Acute should be less in '23 than in '22?
Steve Filton: Yes, I mean we definitely saw our acute care peers raising wage rates, often multiple times during 2022, and again particularly during COVID surges. As I said, I mean I think that our hope is that with COVID volumes more stable, and hopefully without another really significant surge, like we saw in January '20 and January '21, wage rates will be more reasonable, and wage rate increases will be more reasonable in 2023. Look, the other issue is, I think as most people know, I mean I think most of our not-for-profit peers are struggling financially, and then that may be an understatement. So I think, again, the hope is that their willingness to give what we believe will be characterized as outsized pay increases, they're going to have much less of an appetite for that in 2023 than maybe they did in '21.
Pito Chickering: Great, thanks so much.
Operator: Thank you. And one moment for our next question. And our next question comes from the line of Sarah James with Barclays. Your line is open. Please go ahead.
Sarah James: Thank you. You said in your prepared remarks that you were able to lower the previous admission cap in Behavioral due to filling the vacant positions. Can you give any color on what percentage of admissions you had to turn away in 3Q, and what that looked like pre-pandemic?
Steve Filton: Yes, Sarah, we generally donât give those metrics because I think they're hard to measure across the portfolio consistently, not every hospital tracks it the same way, et cetera. We do try and track it, but internally. But I've been reluctant to give those metrics out publicly. And what I will say is what we do know during the pandemic is that the percentage of inbound call volume or -- we call it call volume, but it could be over the internet, et cetera, that we were able to satisfy was significantly lower than it was pre-pandemic. And the main reason for that was because of again, I'm going to describe it as capped beds. And the beds could have been capped either because we were isolating COVID patients in certain units or because we didnât have enough staff. And again, what we have manifested many times when COVID volumes decline is we know that the number of uncapped beds increase as COVID volumes come down. It's difficult to give a precise impact of that. But again, I think you can see it in the 8% same-store revenue growth in Q3.
Sarah James: Got it. And given the, roughly, $200 million reduction in CapEx guide in conjunction with your commentary in 2Q that you're leaning on de novo openings this year related to staffing shortages. What impact does that have on openings going forward? And is it influencing your thoughts around what new builds might happen in '23?
Steve Filton: I think it's mostly a timing issue. I think that we have a view that CapEx investments that make economic sense that pencil out to a reasonable return, et cetera, make sense. They may not make sense from a timing perspective to add capacity in an environment in which we're already having difficulty staffing the existing capacity we have. But ultimately, they'll get built. So, I donât know that there's any 2022 -- because the reality is 2023 large expansion projects that would be adding capacity -- scheduled capacity are probably already well-committed too. I think that our deferral or delay in CapEx probably pushes out some '24 projects to '25, and '25 to '26, it's that sort of thing, rather than, I think, an immediate impact in '23.
Sarah James: That makes sense. Thank you.
Operator: Thank you. One moment for our next question. And our next question comes from the line of Noah Comen with FactSet. Your line is open. Please go ahead. Noah, your phone may be on mute.
Operator: All right, I am showing no further questions at this time. And I would like to turn the conference back over to Steve Filton for any further remarks.
Steve Filton: We'd just like to thank everybody for their time this morning, and look forward to --
Operator: Please go ahead. This does conclude today's conference call. Thank you for participating. You may all disconnect. Everyone, have a great day.
