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Edited Transcript of HCA earnings conference call or presentation 30-Apr-19 2:00pm GMT

Q1 2019 HCA Healthcare Inc Earnings Call

NASHVILLE May 3, 2019 (Thomson StreetEvents) -- Edited Transcript of HCA Healthcare Inc earnings conference call or presentation Tuesday, April 30, 2019 at 2:00:00pm GMT

TEXT version of Transcript

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Corporate Participants

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* Samuel N. Hazen

HCA Healthcare, Inc. - CEO & Director

* W. Mark Kimbrough

HCA Healthcare, Inc. - VP of IR

* William B. Rutherford

HCA Healthcare, Inc. - Executive VP & CFO

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Conference Call Participants

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* Albert J. William Rice

Crédit Suisse AG, Research Division - Research Analyst

* Anagha A. Gupte

SVB Leerink LLC, Research Division - MD of Healthcare Services & Senior Research Analyst

* Ann Kathleen Hynes

Mizuho Securities USA LLC, Research Division - MD of Americas Research

* Benjamin Whitman Mayo

UBS Investment Bank, Research Division - Equity Research Analyst of Healthcare Facilities and Managed Care

* Brian Gil Tanquilut

Jefferies LLC, Research Division - Equity Analyst

* Frank George Morgan

RBC Capital Markets, LLC, Research Division - MD of Healthcare Services Equity Research

* Gary Paul Taylor

JP Morgan Chase & Co, Research Division - Analyst

* Jesse Aaron Klink

Piper Jaffray Companies, Research Division - Research Analyst

* Joshua Richard Raskin

Nephron Research LLC - Research Analyst

* Kevin Mark Fischbeck

BofA Merrill Lynch, Research Division - MD in Equity Research

* Matthew Dale Gillmor

Robert W. Baird & Co. Incorporated, Research Division - Senior Research Analyst

* Matthew Richard Borsch

BMO Capital Markets Equity Research - Research Analyst

* Michael Anthony Newshel

Evercore ISI Institutional Equities, Research Division - Associate

* Peter Heinz Costa

Wells Fargo Securities, LLC, Research Division - MD and Senior Analyst

* Philip Chickering

Deutsche Bank AG, Research Division - Research Analyst

* Ralph Giacobbe

Citigroup Inc, Research Division - Director

* Scott J. Fidel

Stephens Inc., Research Division - MD & Analyst

* Stephen Vartan Tanal

Goldman Sachs Group Inc., Research Division - Equity Analyst

* Steven James Valiquette

Barclays Bank PLC, Research Division - Research Analyst

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Presentation

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Operator [1]

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Welcome to the HCA Healthcare First Quarter 2019 Earnings Conference Call. Today's conference is being recorded. At this time, for opening remarks and introductions, I would like to turn the call over to Vice President of Investor Relations, Mr. Mark Kimbrough. Please go ahead, sir.

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W. Mark Kimbrough, HCA Healthcare, Inc. - VP of IR [2]

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Okay. Thank you, Cody. Good morning, and welcome to all of you on today's call and our webcast. With me this morning is our CEO, Sam Hazen; and Bill Rutherford, our CFO, which will provide comments on the company's results for the first quarter.

Before I turn the call over to Sam, let me remind everyone that should today's call contain any forward-looking statements, they're based on management's current expectations. Numerous risks, uncertainties and other factors may cause actual results to differ materially from those that might be expressed today. Many of these factors are listed in today's press release and in our various SEC filings. Several of the factors that will determine the company's future results are beyond the ability of the company to control or predict. In light of the significant uncertainties inherent in any forward-looking statement, you should not place undue reliance on these statements. Now the company undertakes no obligations to revise or update any forward-looking statements, whether as a result of new information or future events.

On this morning's call, we may reference measures such as adjusted EBITDA and net income attributable to HCA Healthcare, Inc. excluding losses and gains on sales of facilities, which are non-GAAP financial measures. A table providing supplemental information on adjusted EBITDA and reconciling to net income attributable to HCA Healthcare, Inc. to adjusted EBITDA is included in today's first quarter earnings release.

This morning's call is being recorded, and a replay will be available later on today. With that, I'll now turn the call over to Sam.

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Samuel N. Hazen, HCA Healthcare, Inc. - CEO & Director [3]

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All right, thank you, Mark. Good morning to everyone, and thank you for joining us today. Earlier today, we reported a great start to 2019. The results for the quarter were driven by strong revenue growth and improvements in operating margin. Revenue grew by almost $1.1 billion, close 10% in the quarter. This growth was driven by volume growth in commercial business, volume growth in more complex services and new acquisitions. On a same-facilities basis, revenue grew by $700 million or 6.3%. Inpatient admissions and equivalent admissions on a same-facilities basis grew 0.9% and 1.8%, respectively, in the quarter. We estimate the flu volumes from last year had an approximate 1% unfavorable impact on our volume growth this year. Volume growth was broad-based across most service categories and balanced across our markets. The growth in revenue translated into solid earnings in the quarter, with diluted earnings per share of $2.97. Adjusted EBITDA grew by 20% to over $2.5 billion, with adjusted EBITDA margin at 20.3%. As a result of this quarter's results, we are raising our guidance for the year. Bill will provide more details on our metrics and updated 2019 guidance in his comments.

The first quarter continued the positive momentum we have seen over the past 6 quarters. Commercial adjusted admissions grew in each of these quarters. Also, we have now grown our same-facilities inpatient admissions in 20 consecutive quarters. The strategic investments in our business to expand our networks and improve our clinical capabilities are making it easier for patients to get high-quality convenient patient care in an HCA Healthcare facility. The most recently available inpatient market share data showed good growth for the company. We grew by over 50 basis points to an all-time high of 25.3%. We have almost $4.3 billion of capital spending in the pipeline that we expect to come online over the next few years. These investments will create additional inpatient and outpatient capacity within our local health care systems.

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demand for health care services.

We also believe we're well positioned for growth as we continue to execute our operational initiatives, improve the overall competitive positioning of our local health care systems and integrate our acquired hospitals. During the quarter, we announced the acquisition of a majority interest in the Galen College of Nursing. We are excited about this pending deal. HCA Healthcare has been investing heavily in nursing over the past few years, so our nurses can be successful and provide the best possible patient care. This investment creates new opportunities for Galen to expand programs into more of our markets.

And finally, I want to thank our employees and physicians for their great work in delivering high-quality care to our patients. With that, let me turn the call over to Bill.

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William B. Rutherford, HCA Healthcare, Inc. - Executive VP & CFO [4]

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Great. Thank you, Sam, and good morning, everyone. I will cover some additional information relating to the first quarter results, then we will open the call for questions. As Sam mentioned, we are pleased with the first quarter results. For the quarter, adjusted EBITDA increased 20% to $2.541 billion, up from $2.118 billion last year. As noted in our release, the first quarter 2019 results include an $86 million increase to our revenues as a result of finalizing an arbitration related to past out-of-network claims.

So let me cover some volume stats. During the first quarter, same-facility Medicare admissions and equivalent admissions increased 0.4% and 2%, respectively. This includes both traditional and managed Medicare. Same-facility Medicaid admissions increased 2.5%, and equivalent admissions increased 0.3% in the quarter. Our commercial admissions increased 1.3% and equivalent admissions increased 2.5% on a same-facility basis in the first quarter compared to the prior year.

Same-facility self-pay and charity admissions were unchanged in the first quarter compared to the prior year. Same-facility emergency room visits declined 2.3% in the first quarter compared to the prior year. We attribute about 130 basis points to this year's weakened flu season. Additionally, when we look at the changes by acuity level, all of the first quarter declines are in our level 1 through level 3 visits, which declined 7%. Our higher-acuity level 4 and 5 visits grew 2.2% over the prior year. In addition, admissions to the emergency room increased by 1.7% over the prior year.

Same-facility revenue per equivalent admission increased 4.4% in the quarter. The arbitration settlement accounted for 80 basis points of this increase. We are pleased with the overall rate trends we experienced in the first quarter as we saw continued growth in acuity, good payer mix as well as the incremental Medicare update. We believe our visibility around commercial rate remains solid as we have a significant percentage of our commercial contracts completed for 2019 and 2020 at terms and rates consistent with our recent trends.

Now let me turn to expenses. We are pleased with the overall management of expenses. Adjusted EBITDA margins in the first quarter were 20.3% as reported, and our same-facility adjusted EBITDA margins increased 200 basis points over the prior year. On a consolidated basis, total labor cost improved 120 basis points, supply cost improved 50 basis points, and other operating expenses improved 10 basis points.

So let me take a moment to talk about earnings per share and cash flow. As reported diluted earnings per share in the first quarter of 2019, excluding gains and losses on sale of facilities, was $2.97 versus $2.33 in the first quarter of last year. In the first quarter, cash flow from operations was $974 million versus $1.283 billion in the first quarter of last year. The primary item that negatively impacted the year-over-year comparisons was that, in the first quarter of 2019, we funded $428 million for our 401(k) match for 2018. This item was included in our 2019 plan and cash flow from operations guidance.

Capital spending for the first quarter was $781 million, in line with our expectations. During the first quarter, we paid $278 million to repurchase 2.1 million shares, and have 1.995 million remaining on our previous authorization as of March 31, 2019.

Also as mentioned in our release this morning, our Board of Directors have declared a quarterly cash dividend of $0.40 per share.

At the end of the quarter, we had $2.2 billion available under our revolving credit facilities, and our debt-to-adjusted EBITDA ratio was 3.71x. As noted in our release, we've increased our 2019 guidance with adjusted EBITDA now expected to range between $9.45 billion and $9.85 billion, and earnings per share are expected to range between $9.80 and $10.40 per diluted share. Revenue and capital guidance remains unchanged.

So that concludes my remarks. I'll turn the call back to Mark to open it up for Q&A.

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W. Mark Kimbrough, HCA Healthcare, Inc. - VP of IR [5]

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Thank you, Bill (Operator Instructions) Cody, you can now give instructions to those who may want to ask questions.

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Questions and Answers

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Operator [1]

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(Operator Instructions) And we'll take our first question from Gary Taylor with JPMorgan.

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Gary Paul Taylor, JP Morgan Chase & Co, Research Division - Analyst [2]

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I had a few quantitative questions, but I guess I'll just ask the biggest one. After such a really strong quarter, at least dramatically stronger than the Street was expecting, you only raised the annual guidance by $100 million or slightly more than the extent of the arbitration gains. So is there just an abundance of conservatism in the forward guidance? Did the Street really have the first quarter just mis-modeled? Or is there anything else in the year that gives you a little bit of caution at this point in terms of raising guidance further?

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Samuel N. Hazen, HCA Healthcare, Inc. - CEO & Director [3]

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Okay, Gary, I'll let Bill touch on it.

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William B. Rutherford, HCA Healthcare, Inc. - Executive VP & CFO [4]

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Gary, this is Bill, I'll start and Sam can add in. So we typically don't address guidance after just 1 quarter, but given our performance, we believe it was appropriate. And as you said, one way to look at it is the raise is due to the payer arbitration, which wasn't in our original guidance. We continue to see momentum as we saw when we turned the calendar in the core operations and acquisitions improving. As I think about it, if you look at the remaining 9 months of the year, and after considering that last year, we booked some Harvey insurance proceeds in the professional liability, our new reflected guidance has about a 6% growth at the midpoint and almost 9% growth at the high point. So at this point, we think that's appropriate. We'll continue to evaluate it as the year goes on, but I do think we continue to see momentum in the core operating of the business.

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Operator [5]

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We'll now take our next question from Pito Chickering with Deutsche Bank.

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Philip Chickering, Deutsche Bank AG, Research Division - Research Analyst [6]

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Nice quarter. First quarter, it seems your revenue was obviously sort of very strong, and we saw some nice SG&A leverage as expected. Excluding sort of the $86 million from the out-of-network revenue, didn't look to be any leverage on the OpEx line. And I'm just curious if you can walk us through if that was due to acquisitions or how we should think about OpEx leverage with same-store revenues up [as strength].

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William B. Rutherford, HCA Healthcare, Inc. - Executive VP & CFO [7]

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Well, I guess, we look -- there was operating expense leverage. We had a nice margin expansion for the year. If you look at almost any line item, especially on a same-facility basis, we had 200 basis points margin expansion even on a same-facility basis. So as we've talked about in the past, when we're on the top side of our revenue guidance, we do expect to see margin expansion and indeed, we saw that for the quarter.

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Samuel N. Hazen, HCA Healthcare, Inc. - CEO & Director [8]

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And let me just add a couple things here, Bill. We did $700 million of same-stores revenue growth, and we cleared about 54% of it to the EBITDA line. So our same-stores EBITDA margin jumped almost 200 basis points, which really is above sort of our expectation on an incremental revenue clearance standpoint. So we're not seeing the same thing there, Pito, that you're seeing. Our overall operating expense per adjusted admission was only up 1.7% on a same-stores basis, again, well underneath our revenue per unit. And so we were pretty pleased and actually quite pleased with the expense metrics for the company.

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Operator [9]

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We'll hear now from A.J. Rice with Crédit Suisse.

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Albert J. William Rice, Crédit Suisse AG, Research Division - Research Analyst [10]

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Maybe just -- I was actually going to pursue that a different way. It looked like relative to us, that your salary and benefits and supply expense -- I know you've got leverage from outperforming on the revenue line, but they look particularly strong in terms of the ratios. Is there any particular initiatives that you're pursuing that would be worth highlighting there? And I know specifically on the supply side, I think you announced a -- I don't know if you've announced it, but I think there's a new PBM contract that you have. Is that going to move the needle for you in any significant way?

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Samuel N. Hazen, HCA Healthcare, Inc. - CEO & Director [11]

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This is Sam, A.J. And thanks for that. I think HCA Healthcare in general is in a constant pursuit of trying to find ways to gain efficiencies and improve profitability. And so I wouldn't say anything is necessarily that new in our mindset. I mean, we're constantly finding opportunities, we believe, across the company as we get better analytics, as we do better benchmarking, and as we come up with technology solutions that we believe can yield value. And so we do have a number of initiatives connected to those 3 categories. With respect to the PBM relationship, there was an announcement about a transition, but that will take effect in 2020. And we've had a great relationship with CVS in the past. We had a compelling offer put in front of us by Optum and we chose to pursue that, so we'll transition to that relationship next year. But that's just part of our ongoing renewal process inside of our supply chain efforts, and they do a great job of evaluating different opportunities and different approaches as contracts come up for renewal. But I think our teams are very disciplined in their day-to-day activities. They do a great job of managing variable expenses, and then the company is doing a good job in trying to find ways to reduce fixed costs and create a platform that allows our revenue growth to really clear to the bottom line appropriately. So we just continue on sort of the same pathway, is what I would tell you. Obviously, there's questions about wages and so forth. We've been able to maintain wages around our expectations. We're slightly under 3%. We've been able to find ways to improve productivity in the face of what I would call decent volume growth, but not great volume growth, so that was encouraging. And then we continue to execute on our nursing and human resource initiatives, which are yielding reduced turnover, reductions in contract labor, and all that played a part in the performance in the quarter.

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Operator [12]

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We'll take our next question from Frank Morgan with RBC Capital Markets.

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Frank George Morgan, RBC Capital Markets, LLC, Research Division - MD of Healthcare Services Equity Research [13]

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You referenced recent acquisitions in terms of its contribution to your results. Just curious if you could give us a little update on a couple of those recent ones, be it Mission or Savannah, Houston. And I noticed that you also talked about a higher level of CapEx investment, I think $4.3 billion now up from about $3.5 billion last quarter. Any more color around where that's going to be allocated? Is that more into recent acquisitions? Just any color there?

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William B. Rutherford, HCA Healthcare, Inc. - Executive VP & CFO [14]

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Frank, this is Bill. Let me start with the acquisition performance, and we're very pleased with the performance of the acquisitions. They're on plan. First, as you mentioned, Mission's going very well. We're just 2 months into it, obviously, but we're excited for Mission Health to join the HCA network. We're pleased with how the integration is going and their performance is on plan at this point. Memorial in Savannah had a good quarter, continue to operate on their plan, so very solid performance from Savannah. We're also very pleased with our performance of our North Cypress facility in Houston, this is also on plan. So overall, we're right where we anticipated to be. If you recall, as we had our year-end call, we anticipated the acquisitions to contribute roughly 3% of EBITDA growth in '19, and they achieved that level in the first quarter. So very pleased with the performance and seem to be on track with what our expectations were. On the capital increase, yes, there is some increased capital related to Mission, and then as we continue to see opportunities in the market. But our capital spend and trends are on line with what we originally guided.

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Samuel N. Hazen, HCA Healthcare, Inc. - CEO & Director [15]

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Yes, but most of that step-up, Bill, is related to sort of existing markets. The $3.5 billion [rate] to the $4.3 billion, there are a few projects that are related to our acquisitions. But most of that is the continuing investments in our existing markets where we believe we have significant opportunity to improve our network positioning, to increase capacity in key areas and drive technology improvements along certain service lines that we think are differentiators for HCA, and we continue to invest in that at this particular point in time.

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Operator [16]

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And we'll then move on to our next question from Peter Costa with Wells Fargo.

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Peter Heinz Costa, Wells Fargo Securities, LLC, Research Division - MD and Senior Analyst [17]

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Nice quarter. A couple of your competitors seemed to see a little bit faster medical admissions and a little bit slower growth in surgical admissions. You didn't seem to have that issue. Could that be because that you're taking share in the surgical side and the other guys are not taking as much share? And this is something going on with the market or do you think it's just totally separate companies and geographies?

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Samuel N. Hazen, HCA Healthcare, Inc. - CEO & Director [18]

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This is Sam. Thanks for that question. Our inpatient surgeries were flat in the quarter. A lot of that was driven by some C-section reductions, but our outpatient surgeries, conversely, were up, and especially inside of our hospital-based outpatient surgery centers, which were up 3%. So one thing we did have in the first quarter is we had 1 less surgical day. And so the calendar does not present what I would call a favorable calendar and surgical set of days. And so that yielded some pressure on surgery. So if you look at surgery on a per business day standpoint, which is how we look at it, we had really strong surgical activity. I think the company's efforts around creating what we call the OR of choice has been very productive for us. We've been on this journey since 2012 to improve the operations of our surgical suites and appeal to our surgeons in a way that create efficiency, better nursing, better technology offerings and so forth inside of our surgical suites. When you couple that with better improvements in patient satisfaction, it yields a pretty positive result. The other thing I will tell you is that some of the deep service line capabilities that we are building or have built are surgically oriented in nature. For example, trauma is heavily surgery oriented; burn, heavily surgery oriented; cardiovascular, a lot of surgical growth this quarter for us in cardiovascular. And even our robotics investments that we've made have been very productive for us as we look at surgery across the line. As I mentioned in my comments, the company has achieved a high watermark on its inpatient market share. We think that's fairly broad-based across different service lines, which include these surgery components. So we're very pleased with our surgical initiatives, the investments that we're making, and we think broadly, it's having an impact in the market with our physicians and with our patients, and it's yielding pretty solid growth for us.

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Peter Heinz Costa, Wells Fargo Securities, LLC, Research Division - MD and Senior Analyst [19]

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And just, if I could have a follow-up. Given the strength in surgeries that you're showing and the strength from the acquisitions, isn't it time to come off your long-term EBITDA growth rate target of 4% to 6%?

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Samuel N. Hazen, HCA Healthcare, Inc. - CEO & Director [20]

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Well, we're not ready to do that yet. So obviously, this year we guided above that and last year we did perform above that, and we'll have to evaluate that as we get through the rest of this year and look at some of the other factors that are important to long-term guidance. But we hear your point and your question, and it's not a bad question by any means, and we're working our way through it. I think it's important to understand, we're pushing 100% on as many fronts as we possibly can. And if we can produce 20% EBITDA growth like we did this quarter, we'll do that. And so I don't think the management team is trying to beat down the performance of this company. We're trying to lift it up wherever we can find it and we understand the guidance is a part of that, but we will continue to look at that as we move through the rest of the year.

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Operator [21]

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And we'll now take our next question from Mike Newshel with Evercore ISI.

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Michael Anthony Newshel, Evercore ISI Institutional Equities, Research Division - Associate [22]

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Can you guys comment on the IPPS proposal for 2020 and the company-specific impact? And what does your 2019 guidance assume for the calendar fourth quarter? Does it reflect this favorable proposal or a lower, more typical average?

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William B. Rutherford, HCA Healthcare, Inc. - Executive VP & CFO [23]

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Mike, this is Bill. I'll take it. Obviously, we're looking at that proposal, as everybody else. It's still early, so we haven't quantified it yet. We will continue to evaluate that as we go through the comment period, so no specifics on there. Relative to our guidance, I will say our guidance anticipated in the fourth quarter that we will return back to kind of a normal Medicare rate update. We did have a favorable rate this year that we're in that we talked about on the year-end call. So our guidance did presume that we go back to a normal rate. So we'll have to see what that final IPPS rate turns out to be once we go through the comment period. And when we get closer, we'll comment on the quantification of that.

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Operator [24]

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We'll take our next question from Ann Hynes with Mizuho Securities.

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Ann Kathleen Hynes, Mizuho Securities USA LLC, Research Division - MD of Americas Research [25]

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Can you give us some detail? I think the investment in Galen College of Nursing is interesting. How do you think that will improve expenses over time? And maybe when will we see that investment hit the income statement?

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Samuel N. Hazen, HCA Healthcare, Inc. - CEO & Director [26]

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So the Galen College of Nursing is a very exciting acquisition for HCA Healthcare. This is a very impressive organization. We think their culture lines up great with HCA. Their strategy and their discipline around standardization and how they scale their solutions was very impressive to us. And so we see this as an opportunity to put on the front end of our nursing agenda, an education component that will allow us to interact with nursing students early on in their journey to be a nurse, and hopefully integrate them into the HCA Healthcare network in a way that allows us to source talent for our investments in our growth and so forth. As far as expenses, we see some opportunities to use their platform as we expanded in our broader education initiatives. HCA has a very robust clinical education agenda that's underway, and we see the Galen College of Nursing as being very complementary, and in some cases synergistic with that particular effort. We haven't put a number to that as of yet. We have to close this deal hopefully by the end of this year through a regulatory process that we're going through currently. But once we get through that, we're going to be fairly quick in trying to expand their model into different HCA markets so that we can get moving on it. But we don't have any numbers yet specifically on expense synergies, but we do think it's going to create opportunities for us to enhance the pipeline of nurses into our company.

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Operator [27]

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We'll take our next question from Matthew Gillmor with Robert W. Baird.

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Matthew Dale Gillmor, Robert W. Baird & Co. Incorporated, Research Division - Senior Research Analyst [28]

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Following up on Peter's question, can you quantify the calendar impact on volumes? And then did the Hurricane Michael have any lingering impact on the Panama facility that impacted overall volumes at all?

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Samuel N. Hazen, HCA Healthcare, Inc. - CEO & Director [29]

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This is Sam. Thank you for that question. On the second part of your question, the short answer is no. Our Gulf Coast Medical Center in Panama City, that's an incredible group of people down there, and what they went through and how quickly they rebounded. And I want to take the opportunity, since you asked the question, to thank them again for everything they've done. So we're off and running fully at that particular hospital. So our corporate teams, our local teams, other markets supported that hospital in getting up and running, so it had no impact on the quarter as it relates to volume. I think the way we look at surgery, especially on the outpatient side, almost 95% to 98% of all outpatient surgeries are done on weekdays. So when you look at 1 less weekday in the quarter, and then you put the outpatient surgeries on top of that, you can get the sense of what our per calendar day -- or business day, rather, surgical volumes were. I'm not doing the math here on my phone, but nonetheless, that will give you some sense of it. On the inpatient surgery side, it's not as much. We do, do surgeries on the weekends, mainly for emergency patients, but it's a small number. So I think the inpatient surgeries are also influenced by the business day calendar, but not nearly as much as the outpatient. And then you have the same kind of impact on cardiology business, which the company had tremendous cardiology growth in the quarter. Our cardiac volumes were up 3% on the procedure side. Our electrophysiology volumes were up 5%. Again, that's in the face of a business calendar that was a little softer than the previous year, and our cardiovascular surgeries were up 4%. So very solid growth in that particular service line as well. And I think, again, somewhat impacted by the calendar, but we overpowered that as we went through the quarter.

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Operator [30]

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We'll take the next question from Whit Mayo with UBS.

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Benjamin Whitman Mayo, UBS Investment Bank, Research Division - Equity Research Analyst of Healthcare Facilities and Managed Care [31]

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Sam, I don't want to jump the shark, but assuming that we may see some CON law changes in Florida, maybe mostly around some tertiary services, what does this mean for HCA?

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Samuel N. Hazen, HCA Healthcare, Inc. - CEO & Director [32]

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Well, we have not seen the final rules on the CON regulation changes in Florida as of yet. Florida is fairly relaxed currently on a lot of their CON rules. There's no restrictions of any significance on expansion of existing facilities. There are opportunities to do certain outpatient facilities without certificate-of-need requirements. So it has gradually relaxed itself over the years. I mean the opportunity for us with the new hospitals, potentially, in certain markets, it would also mean new programs. For example, rehab is a very restricted CON process today, so our opportunity to get into that service line would be potentially available to us if the CON rules are changed on that front. And then there's a few other programs where there are some restrictions that, as we understand it, could be relaxed. So we'll learn more as this bill continues to progress through the legislative process.

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Operator [33]

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We'll now take our next question from Ralph Giacobbe with Citigroup.

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Ralph Giacobbe, Citigroup Inc, Research Division - Director [34]

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Are there more of these larger arbitration cases outstanding? I know they happen from time to time, just trying to get a sense of whether there's more of a bolus at this point. And were the out-of-network related to exchanges specifically? Or was it broader commercial? And over what period time?

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William B. Rutherford, HCA Healthcare, Inc. - Executive VP & CFO [35]

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Yes, Ralph, this is Bill. From time to time, we have discussions and disputes with payers that result in arbitration, and this was one of those. I can't say that there's a big one now that we see near term. This did relate to health insurance exchange activity in the early periods of health reform, principally '14, '15, with a little bit of '16.

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Operator [36]

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We will now move on to our next question from Kevin Fischbeck with Bank of America.

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Kevin Mark Fischbeck, BofA Merrill Lynch, Research Division - MD in Equity Research [37]

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Just wanted to dig into the margin improvements since that seems to be where the biggest surprise was, and I guess maybe labor in particular. I guess we're all kind of assuming that as the economy keeps improving, that wages are going up and that this will be more of a pressure on you going forward. But really good labor cost growth in the quarter, so I just want to understand what was driving that and how you think about that number tracking through the year.

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Samuel N. Hazen, HCA Healthcare, Inc. - CEO & Director [38]

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I spoke to most of the details a minute ago on labor and how we viewed it. Again, if you look at same-stores for the company, our labor cost were up 3.6% on revenue growth of 6.3%. We were able to find some productivity inside of that and manage our wages, as I've said, under 3%. So we had good reductions in contract labor, and I just think overall, really well managed by our facilities. Obviously, when we have commercial volume and we have high-intensity volume, we aren't using a ton of marginal cost to support that. We're using some marginal cost for sure, but because it's got more revenue turnover and more revenue yield per patient, if you will, it clears more effectively. And that shows itself in the margin expansion that I mentioned as well earlier in the call, and it shows itself significantly in labor as well, when you figure roughly 50% of our labor costs in HCA are fixed in nature. And so to the extent we have some volume growth, but really good volume growth as far as the mix of that volume, it clears itself pretty effectively through the different expense categories, and that's what we saw in the first quarter. As it relates to the rest of the year, we're not anticipating anything significantly different with respect to labor pressures. We continue to execute the multiple agendas that we have to improve our environment for our employees so it's a better place to work and more attractive to them, and we don't see any unusual cost pressures coming from that.

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Operator [39]

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We'll take the next question from Josh Raskin with Nephron Research.

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Joshua Richard Raskin, Nephron Research LLC - Research Analyst [40]

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I guess it's been a little while since we talked about taking risk, and I'm just curious if you're seeing any changes in the market or payer expectations or even on the HCA side in terms of your appetite to be taking more risk, I guess, sort of attitudes from payers, et cetera, everything along that line.

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Samuel N. Hazen, HCA Healthcare, Inc. - CEO & Director [41]

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This is Sam. Thank you for that question. Nothing in our view has changed materially across our 43 different markets. We continue to interact with the payers I think very effectively and strategically in many instances. I think the approach that we take to building out our network with various outpatient facilities that have different price points is productive for the payers and, at the same time, very convenient and efficient and satisfying for our patients. That's been effective for us. We do have some contracts where there are value-based provisions in them and so forth. I think what people fail to recognize is that HCA, on a roughly 75% to 80% of its inpatient admissions, takes a form of risk in that we get DRG payments or we get a case rate payment on a particular patient, and it's our responsibilities to manage efficiently underneath that. And so we're taking forms of risk. We're not taking risk outside of the walls of the hospital in any material way because we don't feel we're in a position to control that or influence that or even price that, necessarily. So our approach has been to focus on risk parameters that we can control, that we have some visibility into, and then be a really productive partner for the payers by meeting their needs with different facility offerings, with very efficient high-quality outcomes that don't result in readmissions or don't result in infections and longer lengths of stay and such. And so that's been our approach, and we think that generally is workable with the payers. So we aren't really seeing any significant changes broadly across the marketplace.

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Operator [42]

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We'll take our next question from Scott Fidel with Stephens.

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Scott J. Fidel, Stephens Inc., Research Division - MD & Analyst [43]

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Interested if you could just touch on some of the key factors that drove the year-over-year change in operating cash flows, particularly as it relates to the DSOs. And then maybe update us just on anything to call out around the quarterly cadence of operating cash flow over the remainder of the year.

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William B. Rutherford, HCA Healthcare, Inc. - Executive VP & CFO [44]

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Yes, Scott, this is Bill. So as I called out in my comments, the most significant item that affected the year-over-year cash flow was our 401(k) match that we funded in the first quarter related to 2018. There are a couple other items that affected it. The payer settlement we spoke to went into receivables in the first quarter, we've subsequently collected that in April. With the Mission AR acquisition, there were some increased receivables just given we were 2 months into that, both those were in the $80 million range. So when we adjust for those, our cash flow for ops is right on track. We continue to believe, for the full year, cash flow from ops will range between $6.5 billion and $7 billion. And so we feel good about where the company is positioned on that. I think as the company continues to see some growth in earnings, we'll see that growth in cash flow operations as well.

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Scott J. Fidel, Stephens Inc., Research Division - MD & Analyst [45]

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So original, like, guidance was $6.5 billion to $7 billion for the year?

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William B. Rutherford, HCA Healthcare, Inc. - Executive VP & CFO [46]

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$6.5 billion to $7 billion, yes. And we continue to believe that's the proper guidance for HCA.

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Operator [47]

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Our next question will come from Steven Valiquette with Barclays.

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Samuel N. Hazen, HCA Healthcare, Inc. - CEO & Director [48]

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Steve?

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Steven James Valiquette, Barclays Bank PLC, Research Division - Research Analyst [49]

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Hello?

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Samuel N. Hazen, HCA Healthcare, Inc. - CEO & Director [50]

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Hey, Steve.

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Steven James Valiquette, Barclays Bank PLC, Research Division - Research Analyst [51]

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Sorry, for the bad connection on the cellphone, hope you can hear me. I just wanted to follow up. Okay, so just separate from the surgery discussion earlier, there has been discussion this quarter among your peers on softer same-store revs per adjusted admission that may be happening for other reasons as well. And you guys obviously had pretty good results in 1Q '19 on that metric, and I know there's a ton of variables that go into that metric. But I'm just wondering if you're able to comment on the durability of your results there, just for the rest of 2019, just to give investors more confidence around, again, the same-store revs per adjusted admission metric for HCA for the full year.

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Samuel N. Hazen, HCA Healthcare, Inc. - CEO & Director [52]

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I think, obviously, we benefit from commercial volume growth, and our commercial volume growth, like I've said, we've had 6 consecutive quarters of adjusted admission growth in our commercial segment. And that's yielded strong revenue per adjusted admission. The second thing I would say is, as we build out service line capability and deepen our programs broadly across the organization, that yields more revenue per patient. Those are the 2 factors that drove our revenue per unit up above where maybe people expected. And we've had a pretty good pattern with that. I think in 2018, if I remember correctly, we were north of 3%, and that, again, is a function of those 2 variables. Also when you look at our case mix, our case mix trend, which is not a perfect proxy for acuity, but a good one, is actually trending north of 3% as well. So we continue to invest in both of those components of our business. We have numerous initiatives that are geared towards being more accessible for the commercial population. We have more outpatient investments that are geared towards that. Also, in the service line standpoint, we continue to build out capabilities across the company's portfolio. And again, those things I still think have a room to grow. And as we see continued momentum in the markets with job growth and strong economies, we think that portends reasonably well for us over the course of 2019.

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Operator [53]

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Our next question comes from Steve Tanal with Goldman Sachs.

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Stephen Vartan Tanal, Goldman Sachs Group Inc., Research Division - Equity Analyst [54]

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I wanted to follow-up on that one. I guess the quarter itself was quite good, clearly. The commentary is very bullish. And so I guess the question would be, is there anything that could potentially move you back into the guidance range on revenue per adjusted admit, that's 2 to 3 for the year? Or does it seem like pretty likely to be tracking above?

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William B. Rutherford, HCA Healthcare, Inc. - Executive VP & CFO [55]

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Well, we'll have to see, there's obviously quarter-to-quarter trends we have, but as you heard us talk about, we feel there's a lot of momentum in the growth prospects of the company. As Sam just mentioned, good commercial growth really helps drive that. We continue to invest in the higher-acuity services. So we do anticipate continued strength in the revenue portfolio and the composition of the company. So I think, for the near term, we might be above that, but we'll just have to see what the future quarters yield.

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Stephen Vartan Tanal, Goldman Sachs Group Inc., Research Division - Equity Analyst [56]

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Then maybe just lastly, from anything -- just on the M&A pipeline, any comments there? How is that looking? Are there still opportunities out there? Have you slowed the pace? Any color would be helpful.

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Samuel N. Hazen, HCA Healthcare, Inc. - CEO & Director [57]

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Well, I wouldn't say that we have anything to report on at this particular point in time. It's our judgment, and I mentioned this I think on the last call or maybe the call before that, that we could be entering a cycle where there are some nice opportunities for the company. We are having discussions, but they're early discussions with different systems that are exploring their options as they look at their future and their situation. Most of those are independent not-for-profit systems that we think have some appeal, and so we'll continue those conversations. To say that they're any more than we've had in the past, I really can't say that, but I do think we are entering a period of time where we could see more than we've seen in the past.

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Operator [58]

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We'll take our next question with Ana Gupte with SVB Leerink.

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Anagha A. Gupte, SVB Leerink LLC, Research Division - MD of Healthcare Services & Senior Research Analyst [59]

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So very impressive quarter. You continue to impress and you decouple from the rest of the hospital operators on growth in all of the metrics. So my questions are really about, how much of this is even secular anymore relative to the HCA playbook? And I can ask many, but 2 quick ones would be, your commercial mix has been very impressive. Once, I think a year ago, you maybe talked about market-specific population growth, probably better employment in your markets. Is it that anymore or is it just [shaking] because you're investing so well in service lines and [admin], all of that and with your physicians? And then secondly on the pricing growth, also the rate and the payer mix and acuity, but you're much better than everyone else. Is it also because you have an unparalleled asset base across the inpatient assets, your 2,000-plus [sort of] access points that you're building towards, so you have the ability to optimize your payer mix and your acuity by site of service, if you will? Any comments on that?

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Samuel N. Hazen, HCA Healthcare, Inc. - CEO & Director [60]

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I'm not in a position to speak to the other companies and their results. What I can speak to is how we approach the market and what it takes for us to compete in these large metropolitan markets. And typically, we are competing against a local not-for-profit system or 2, most of which are only in that particular market. Very few of them are what I would call portfolio market players. So we have to adjust our approach to deal with those local nuances, but we have been very effective in transporting ideas, transporting initiatives and investing aggressively in our growth agenda across the company. And our results are broad-based. Our market share on the commercial is at an all-time high. We grew our market share on the commercial book actually slightly better than we grew our overall market share in this last report that we've got. So that's very encouraging. We continue to believe we're doing the right things, again, from a payer standpoint in relating to them and finding ways to be a solution for them and, at the same time, creating an efficient and satisfying experience for the patient. So a lot of our commercial revenue is on the outpatient side. We invest in that. We try to create programs that make it easy for the patients to navigate. And so we'll continue down that pathway because we think it works. And so that's really what we're seeing. It's hard for me to compare against the other companies because I don't get to see their results like I do ours, nor do I understand their business model to the same degree as I understand our competitors across our markets.

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Operator [61]

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We'll hear now from Matt Borsch with BMO Capital Markets.

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Matthew Richard Borsch, BMO Capital Markets Equity Research - Research Analyst [62]

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Just 2 questions on the trend in your services and the demographics. As you look at the weighting towards cardiac services this quarter and, on the other hand, the fewer C-sections that you have, is that -- are we talking aging of the population on the one hand, and the very, very low birthrate on the other? And I'm just curious how you see that developing given that the vanguard of the baby boom generation is now in their early 70s.

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Samuel N. Hazen, HCA Healthcare, Inc. - CEO & Director [63]

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So there's 2 pieces -- this is Sam. There are 2 pieces to that question. On the cardiac side, we are seeing strong cardiology volume trends. Even in the fourth quarter, I think we were up about 5%. And so we're up again about that same level. And that really goes to our service line strategy, which is led by a team up here in Nashville who supports our field teams and physician recruitment, program development, technology deployment, patient navigation, all of those kind of things. And we think that has allowed us to attract physician talents and add program capacity, and that's yielding volume gains for us across the board in cardiology. In the obstetrics world, what's interesting in this quarter, our commercial volume was down significantly. And so that's what drove sort of the overall blend of the metric and yielded some reductions in C-sections. We do see birth rates flattening out across the country. We've spoken to that before. And our approach to women's services has been to really create destination sites in most of our markets, where physicians and moms want to go because we have the facilities, the physician capability, the nursing capability and so forth that creates a very positive environment, and that's working for us in markets where we've made those investments. And we'll continue to look at, again, transporting that idea more broadly so that we can pick up market share. I think for the most recent report, our market share in obstetrics is actually flat, but that -- where we've lost it is, again, in the Medicaid side of the equation, and not so much on the commercial side.

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Operator [64]

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We'll take our next question from Sarah James with Piper Jaffray.

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Jesse Aaron Klink, Piper Jaffray Companies, Research Division - Research Analyst [65]

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This is Jesse on for Sarah. So on the last call, you highlighted that 80% of hospitals grew EBITDA year-over-year, 70% grew admissions year-over-year, 65% of hospitals grew outpatient surgery year-over-year, so all in, 2018 was a really good year. Just wondering how that's trending so far in 2019. If it makes a difficult comp at all? Do you still think there's room for improvement among those facilities? And then if there is room for improvement, just what could that mean for the kind of 2% to 3% volume growth and 4% to 6% EBITDA growth guidance?

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Samuel N. Hazen, HCA Healthcare, Inc. - CEO & Director [66]

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Well, we had a really strong portfolio performance again in the first quarter of 2019. It was very similar to the metrics that you just delineated. We had 75% of our hospitals that had year-over-year EBITDA growth, we had 54% have admission growth. Now some of that is because of the flu season and the impact that the flu season last year had on our year-over-year comparisons. But nonetheless, that's a pretty powerful metric in my judgment, given that we had 1 less business calendar day -- or 1 less business day and then we had the impact of the flu from the previous year. Emergency room volume was a little softer than what I recorded -- reported last year, and again, I think that's due to the flu. But all in all, we had really strong portfolio performance pretty much across the board. We're very pleased with the execution of our strategies by our management teams across the board.

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W. Mark Kimbrough, HCA Healthcare, Inc. - VP of IR [67]

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Cody, we've got time for 2 more questions, okay?

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Operator [68]

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Absolutely. We'll take our next question from Brian Tanquilut from Jefferies.

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Brian Gil Tanquilut, Jefferies LLC, Research Division - Equity Analyst [69]

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Congratulations on a good quarter. Sam, I guess my question for you. As I think about your physician strategy, are you looking at piloting or pursuing any new approaches through in-hospital physician practice ownership? And then, again, as we think about the M&A pipeline, how does that relate to that in terms of your appetite for acquiring in-hospital practices at this point?

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Samuel N. Hazen, HCA Healthcare, Inc. - CEO & Director [70]

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Well, we continue to add to our physician services group, physician practices. I think we're over 5,000 physician practices in H -- or 5,000 physicians, roughly 1,200, 1,400 clinics across the company. And that's growing at roughly 8% to 10% per year. So that's an ongoing trend that we think is part of our success, but at the same time, part of creating an offering for our patients and for our payers that works. As it relates to hospital-based physicians specifically, we are exploring approaches to deal with some of the pressures that exist in the marketplace. We have today hospital-based physician practices that are owned by HCA for critical care medicine. We may have the largest or the second-largest critical care medicine practice in the country. We also have a very large pathology practice inside of HCA that's growing. We are exploring hospitalists, we're exploring emergency room physicians, we're exploring anesthesia in ways that are maybe different than what we've done in the past. We don't have anything today to report as to exactly what that's going to be. How that will impact acquisitions in the future, I don't think it will be a material impact on any acquisitions. It could be synergistic on the margins for some acquisitions in the future if we do have a different approach there. But at this point in time, it's not really that material.

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W. Mark Kimbrough, HCA Healthcare, Inc. - VP of IR [71]

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We got one more.

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Operator [72]

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We'll take our follow-up from Pito Chickering with Deutsche Bank.

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Philip Chickering, Deutsche Bank AG, Research Division - Research Analyst [73]

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Quick question, case mix, I guess quantified that increasing at 3% in the first quarter. Did you disclose the same-store case mix? And also it's been increasing over the past 3 years, mostly due to CapEx investments. With the amount of the CapEx spend in the process, is it fair to think the case mix growth shouldn't slow any time in the next 2 to 3 years?

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William B. Rutherford, HCA Healthcare, Inc. - Executive VP & CFO [74]

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Pito, this is Bill. Our case mix index for the first quarter was 2.6%.

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Samuel N. Hazen, HCA Healthcare, Inc. - CEO & Director [75]

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Same facility.

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William B. Rutherford, HCA Healthcare, Inc. - Executive VP & CFO [76]

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On a same-facility basis on there. There are a lot of service line variables on there. I don't know whether it will slow or not. As we've talked about, our focus both on capital as well as the program development Sam alluded to throughout the call is to continue to grow our high-acuity and high-intensity services. So we've been in a period where we've been north of that for some period of time in this 3 to 4. I've said before, 2 to 3 likely might be a long-term settlement -- settle period. But as we continue to invest capital in the high acuity, as our program development is focused on the higher acuity, I wouldn't be surprised if we still see a robust case mix [in the next quarters].

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W. Mark Kimbrough, HCA Healthcare, Inc. - VP of IR [77]

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Cody?

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Operator [78]

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That concludes today's question-and-answer session. I would like to turn the conference back over to Mr. Kimbrough for any additional or closing remarks.

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W. Mark Kimbrough, HCA Healthcare, Inc. - VP of IR [79]

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Okay. Great. Listen, I want to thank everyone who participated today. Thank you for your interest in HCA, and I will be around the office if you need additional follow-up. Thank you so much.

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Operator [80]

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Thank you. That does conclude today's conference. Thank you all for your participation. You may now disconnect.