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Universal Health Services (UHS) Q2 2019 Earnings Call Transcript

Motley Fool Transcribing, The Motley Fool
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Universal Health Services (NYSE: UHS)
Q2 2019 Earnings Call
Jul 26, 2019, 9:00 a.m. ET

Contents:

  • Prepared Remarks
  • Questions and Answers
  • Call Participants

Prepared Remarks:


Operator

Good morning. My name is Heidi, and I will be your conference operator today. At this time, I would like to welcome everyone to the second-quarter 2019 earnings conference call. [Operator instructions] Steve Filton, you may begin your conference.

Steve Filton -- Chief Financial Officer

Thank you, Heidi, good morning. Alan Miller, our CEO, is also joining us this morning. We welcome you to this review of Universal Health Services' results for the second quarter ended June 30, 2019. During this conference call, Alan and I 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 these forward-looking statements, I recommend a careful reading of the section on Risk Factors and Forward-Looking Statements and Risk Factors in our Form 10-K for the year-ended December 31, 2018 and our Form 10-Q for the quarter ended March 31st, 2019. 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 recorded net income attributable to UHS per diluted share of $2.66 for the quarter. As discussed in our press release and calculated on the Supplemental Schedule, adjusted net income attributable to UHS was 247.2 million or $2.76 per diluted share during the second quarter of 2019.

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This compares to 233.3 million or $2.47 per diluted share of adjusted net income attributable to UHS during the second quarter of last year as calculated on the Supplemental Schedule. On a same-facility basis in our acute care division, revenues during the second quarter of 2019 increased 9% over last year's comparable quarter. The increase resulted primarily from a 5% increase in adjusted admissions and a 3.5% increase in revenue per adjusted admission. On a same-facility basis, net revenues in our behavioral health division increased 2.7% during the second quarter of 2019 as compared to the second quarter of 2018.

During this year's second quarter as compared to last year's, adjusted admission to our behavioral health facilities owned for more than a year increased 0.5%, and adjusted patient days increased 0.3%. Revenue per adjusted admission increased 2.2%, and revenue per adjusted patient day increased 2.4% during the second quarter of 2019 over the comparable prior-year quarter. For the six months ended June 30, 2019, our net cash provided by operating activities increased to 624 million from 607 million generated during the comparable sixth month period of 2018. Our accounts receivable days outstanding decreased slightly to 51 days during the second quarter of '19 as compared to 53 days during the second quarter of '18.

At June 30, 2019, our ratio of debt-to-total capitalization increased to 43.5% as compared to 42.9% at June 30, 2018. We spent $154 million on capital expenditures during the second quarter of 2019 and 324 million during the first six months of 2019. Our board of directors recently authorized a $1 billion increase to our stock repurchase program. In conjunction with previously approved stock repurchase programs during the second quarter of 2019, we repurchased approximately 2.7 million shares of our stock at an aggregate cost of approximately 339.2 million or approximately $125 per share.

During the first six months of 2019, we repurchased approximately 3.6 million shares at an aggregate cost of approximately 445.6 million or approximately $125 per share. Since inception of this program in 2014 through June 30, 2019, we have repurchased approximately 14.2 million shares at an aggregate cost of 1.68 billion or approximately $118 per share. As disclosed in last night's press release, we have recently reached an agreement in principle with the Department of Justice's Civil division and on behalf of various states' attorney's general offices to resolve the civil aspect of the government's investigation of our behavioral health facilities for $127 million, subject to requisite approvals in preparation and execution of definitive settlement and related agreements. We have further been advised that the previously disclosed investigations being conducted by the DOJ's criminal fraud section in connection with these matters have been closed.

We are awaiting the initial draft of a potential corporate integrity agreement with the Office of Inspector General for the United States Department of Health and Human Services, which we expect will be part of the overall settlement of this matter.  In connection with the agreement in principle with the DOJ's Civil division during the three and six months period ended June 30, '19, we have recorded a pre-tax increase of approximately $11 million in the DOJ reserve, which includes related fees and costs due to or on behalf of third parties. The aggregate pre-tax DOJ reserve amounted to 134 million as of June 30, 2019 and 123 million as of December 31st, 2018. Our financial statements assume that the amounts included in the aggregate pre-tax DOJ reserve are fully deductible for federal and state income tax purposes.

Since the agreement in principle with the DOJ Civil division is subject to certain required approvals and negotiation and execution of definitive settlement agreements, as well as negotiation and execution of a potential corporate integrity agreement with the OIG, we can provide now assurance that the definitive agreements will ultimately be finalized. We therefore can provide no assurance that final amounts paid in settlement or otherwise or associated costs or the income tax deductibility of such payments will not differ materially from our established reserve and assumptions related to income tax deductibility. Alan and I are pleased to answer your questions at this time.

Questions & Answers:


Operator

[Operator instructions] And your first question comes from the line of A.J. Rice with Credit Suisse. Please go ahead.

A.J. Rice -- Credit Suisse -- Analyst

Thanks. Hi everybody. Well, you've been dealing with this investigation for quite some time, so it's great to hear that's winding down. I wonder if you have any feeling.

If we look at you compared to your largest peer domestically, your same-store revenue and EBITDA growth have been a little less than them, and we've talked about some reasons historically. But I wonder if you would think that getting this thing done once and for all, is it going to potentially and not necessarily on the next quarter, but the next few quarters, help you in terms of recruiting staffing in some of the key markets where they've been a focus on this? Do you think it'll help you with some of your referral sources?

Steve Filton -- Chief Financial Officer

Well, A.J., I'll make the sort of obvious statement that it can't hurt. But I will say that over the last several years, as objectively and in some cases subjectively as we could, I think we try to determine whether the government investigation was having an impact on our business, on our referral sources, on our clinicians' behavior. And neither objectively, I think, nor anecdotally could we really ever demonstrate that in any sort of material way. Now look, I'll also again state what I think is fairly obvious.

I mean we have expanded substantial dollars in legal fees and other costs to defend this case. So at a minimum, I think on average, our costs associated with defending the case have been in excess of $10 million a year for the last five or six years. So we'll free those costs up. We certainly have dedicated a significant amount of time and effort internally, certainly on the part of some individuals.

I think we've made every effort to try not to distract our operators with the issues of this case. But again, I think there's no way that there's just not sort of a general halo benefit. But I don't think we've ever suggested that there'd be a dramatic and measurable uplift in the business. But like said, it certainly cannot hurt.

Alan Miller -- Chief Executive Officer

A.J., the criminal investigation also came to absolutely to nothing. So you'll have to deal with the existing management for a while.

A.J. Rice -- Credit Suisse -- Analyst

Yeah. Well, we expected that. So the other question obviously, a big bright spot in the quarter was the rebound on the acute care side. And I know you'd said that you thought it was an anomaly in the first quarter, and you can see somewhat of a rebound in the second, which we did.

I wonder if you can comment specifically on the big markets you have, Vegas, Southwest Texas, Southern California. Was it sort of across the board? Or was it focused? And maybe just an update on those.

Steve Filton -- Chief Financial Officer

Sure, A.J. So I think when you have a quarter that has the sort of fundamental strength that we had this past quarter, almost by definition, it has to be fairly broad-based. And I think in fact, it was. And I think for the most part, it follows the, at least, geographic commentary that we've made and been making for a while now.

Las Vegas continues to be strong. Our Henderson facility continues to ramp up. But we're also making capacity expansion additions in any number of our Vegas facilities, and I think those are benefiting as well. The Southern California Riverside County market had a strong quarter.

The Denison, North Dallas market had a strong quarter. Again, that was a market that I think has also benefited from some fairly substantial capital investment in the last year. And we did talk in Q1 about the fact that we expected that some of these capital investments would begin to yield both revenue and EBITDA returns in the back half of the year. And finally, I'll say something I don't think I've said in a while that South Texas McAllen market had a pretty strong second quarter, and that's a market that for the most part has been lagging for us over the last several years.

So that's -- I don't know if that's the beginning of a trend, but it's certainly an encouraging sign.

A.J. Rice -- Credit Suisse -- Analyst

All right. Thanks a lot.

Operator

And your next question comes from the line of Matt Borsch with BMO Capital Markets. Please go ahead.

Matt Borsch -- BMO Capital Markets -- Analyst

Maybe I'll just continue on that line a little bit more. If you could talk about what you're seeing sort of length by service category patient in terms of driving the strengths on acute care. If there's any more granularity you can give us on that.

Steve Filton -- Chief Financial Officer

Sure, Matt. So look, I think the sort of the headline dynamic in Q1 was the fact that our acute care revenue per unit, per adjusted admission, let's say, was certainly lower than our expectations. And we attributed that weakness almost entirely to an unfavorable shift from surgical to medical business and surgical to medical patients. We struggled to really come up with a definitive explanation for that dynamic.

But said that by the end of the first quarter, it seemed to have sort of reversed itself, and we were operating at much -- a more normalized mix levels. And in my appearances at conferences and things in Q2, I think I reiterated that that was clearly true. And I think when you look at the results in Q2, you can see that those trends have been reversed and maybe we recaptured, if you will, some of that, I'll describe it as lost surgical business in the first quarter. I think what I would suggest to people, and I suggest this because I think we think about it this way, as I would look at the first six months of acute care results as sort of a unit and look at those results as being kind of the more sustainable metrics of this business, 6 to 7% revenue growth, I will say that the admission strength, that 5% admission growth, which was pretty much the same in both Q1 and Q2, I'm guessing when we see the other company numbers will be at the high end.

And I'm not sure that those can be sustained indefinitely. But again, that 6 to 7% acute care revenue growth may be a little bit higher than what we had in our guidance, but generally in the ranges of what our expectations were.

Matt Borsch -- BMO Capital Markets -- Analyst

And one more, if I could. As we look ahead to this current third quarter, where you have an extra business day but there's a mix of other things, is there anything that we should think about in terms of the top line volume outlook again to sort of sticking on the acute care side for this current quarter?

Steve Filton -- Chief Financial Officer

Yeah. Candidly, Matt, I don't know that we pay a lot of attention to these calendar issues. I think we have a point of view that all that comes out in the wash over the course of the year. But broadly, I don't think we have any expectation that -- other than sort of the normal kind of seasonal falloff in activity that we get in the summer time, which we would expect to occur this year, just like every year.

I don't know if there's anything other than that that we would specifically call out about expectations for acute care performance in Q3.

Matt Borsch -- BMO Capital Markets -- Analyst

Fantastic. Thank you.

Operator

Your next question comes from the line of Justin Lake with Wolfe Research. Please go ahead.

Justin Lake -- Wolfe Research -- Analyst

Thanks. Good morning. First question on capital deployment. I think the market's going to applaud you for all the share repurchase you did in the second quarter.

Now that the investigation's pretty much behind you, can you give us an update on how investors should expect you to view kind of the capital deployment through the lens of how much of the free cash flow are you expecting to return quarterly and then where you think the right leverage level for these businesses?

Steve Filton -- Chief Financial Officer

Sure, Justin. Look, I think that, first of all, I would suggest that the sort of accelerated level of share repurchase activity in Q2 was a function of a couple of different things. I mean I think that UHS' stock price, along with many of our peers in just healthcare in general, suffered in Q2 as a result of some of the sort of headline noise around Medicare for All and some of the other sort of legislative initiatives. I think we always felt that was largely overdone and view that as a significant and unique buying opportunity.

But I think also more broadly, we certainly had a greater sense that we were nearing the end of this DOJ process. We also, I think, were fairly bullish on the underlying fundamentals of the two business segments. So altogether, I think we were just fairly bullish about the prospects of the company, and I think that was reflected in the share repurchase activity. It's also reflected, I think, in the $1 billion reauthorization that we announced last night.

In terms of sort of committing to a specific level of share buyback or the pace of it or to sort of say what people should expect, I think we're reluctant to do that. I think we've always been an opportunistic buyer. And that opportunistic sort of dynamic depends on a number of factors, including what other opportunities we may find out in the marketplace externally through M&A or otherwise development, what's happening in the stock market, et cetera. So again, I think that we're likely to see a share repurchase pace that's above where we've been the last several years, but not prepared to make any specific commitments today.

Justin Lake -- Wolfe Research -- Analyst

OK. And then if I could just follow up on the behavioral side. You saw a stabilization in length of stay but then a bit of an offsetting drop in volumes. Can you give us any color in terms of do you feel like there's any kind of light at the end of the tunnel on length of stay and then what's going on with volumes?

Steve Filton -- Chief Financial Officer

Yeah. I'd make a couple of points, Justin. One, and I've made this point before, I do think that there is some interplay between the length of stay and admission dynamics, so that when length of stay is coming down, we generally have seen admissions go up. And it's just, I think, a mechanical process of patient beds being vacated sooner and increased admissions to fill those vacancies sort of faster.

And I think this quarter, you saw a little bit of the reverse in that dynamic. As length of stay stabilized, I think you saw admission volume come down a little bit. That's sort of the first point that I'd make. Secondly, I mean we continue to see the dynamic that we've talked about for some time, which is as more patients shift and transition from managed Medicaid -- or excuse me, from traditional Medicaid programs to managed Medicaid programs, we see their length of stay decline.

That overall dynamic or that dynamic was offset overall by a bit of a shift in Q2 from adolescent business to adult business. Adolescents tend to have a longer length of stay than adults, and so I think that offset the Medicaid dynamic at least in Q2. I don't know that that's necessarily a continuing trend. Otherwise, I think generally, the trends remained stable in the behavioral space, and I think we believe that a number of our facilities are poised for volume improvement.

And our expectation has been for some time that the revenue growth in the segment will increase from the sort of 3% that we've been at for the last several quarters to something above that.

Operator

Your next question comes from the line of Sarah James with Piper Jaffray. Please go ahead.

Sarah James -- Piper Jaffray -- Analyst

Thank you. So it sounds like the acute clinical trend was up related to investments to tracking volume, not just deductible wear down and the timing of patient scheduling in 2Q versus 1Q. So I'm wondering if that makes you more bullish on the second half.

Steve Filton -- Chief Financial Officer

Well, Sarah, I mean I think what we've said in Q1 was two things. I mean one is we didn't see any reason why the early weakness in the first six to eight weeks of the year of surgical volumes would likely continue. And in fact, they did not. So I think I would particularly point to inpatient surgical volumes, which were relatively flat in Q1 and up like 3% in Q2.

And that, I think, resulted in significant shift in acuity and revenue per unit. And I think again, I would suggest that that sort of revenue acuity and revenue per unit that we've seen for the first six months ought to generally be more in line with what we see in the second half of the year. So we did also make the point where I think a number of people ask in Q1 about the sort of the guidance ramp and the earnings ramp for the year. And I think we did talk about any number of, I'll call them, mid-sized capital projects in the 20, $30 million range, where we're adding capacity of some sort.

It could be beds. It could be ER capacity. It could be surgical capacity, but in any number of hospitals and markets in Las Vegas; in Denison, Texas; in McAllen. And I think we started to see in Q2 some of that.

So look, honestly, I think we express confidence in our ability to meet our guidance even after Q1, which I think some people found disappointing.But I think certainly after a strong Q2, we're feeling even more confident that our original guidance is very achievable.

Sarah James -- Piper Jaffray -- Analyst

Got it. So it sounds like this was contemplated in your full-year guidance. And I'm wondering if -- since the nice return that you got on these investments for expanding capacity and other areas, does it change your strategy on how competitive you want to be on that front seeing the return that you got on these investments? Could we see a rationale for an uptick in investment spend as part of your growth strategy?

Steve Filton -- Chief Financial Officer

Yeah. Look, I think we have a point of view that we look at capital investment opportunity. We look at almost all capital deployment opportunities on very much of an individual basis. And so I think our point of view is that money well spent, well targeted makes sense in a market where we can demonstrate that demand is there for a particular service or a particular investment.

And that's the way we look at it. I don't think we take the view that if we have kind of a robust quarter, it's all of a sudden reason to invest more, or quite frankly the opposite, if we have a softer quarter that it's reasonable to invest less. I think we have a long track record of being a pretty judicious employer of capital, and that's why I think we have the point of view that as we invested capital in our markets in these strong franchises, that it would earn a return over a reasonable period of expectation as we originally contemplated. And again, I think we're seeing that kick in Q2, and our guess is it will continue to kick in over the balance of the year as our guidance presumes it would.

Operator

Your next question comes from the line of Josh Raskin with Nephron Research.

Josh Raskin -- Nephron Research -- Analyst

Hi. Thanks. Good morning. I guess, Steve, with a little bit more of the details around the settlement known now at this point, I'm curious if you have sort of enough information to know if there's any change in operations expected.

I don't know if that's in the corporate integrity agreement, et cetera. Sort of any business practices that you feel changed because of this?  And then do you have a view on sort of final settlement and timing of disbursement and resolution in totality?

Steve Filton -- Chief Financial Officer

I'll answer the second part, first, Josh. I mean I think we would guess that this whole process will be wrapped up probably by mid-fall. But to be fair and to those who followed us, this -- the cadence of this process is largely in the government's control, so we've not always been as accurate as we would like in estimating these things. Obviously, we're much closer to the end.

And hopefully, that makes it a little bit easier to estimate the time frame in a more accurate way. But that would be our best guess that we can wrap this up completely and tie a ribbon around it by mid-fall, and that would be when we make our payment. As far as changes to operations, look, we've made the point, I think, fairly consistently. We have vigorously defended ourselves for the five or six years of this investigation.

Feel that our processes, our compliance, infrastructure, et cetera, are all fairly robust and quite conscientious. And really, I don't think of it -- with the exception of small tweaks here and there that really changed fundamentally our own internal processes over the course of this investigation. We've not seen a draft of a compliance agreement or corporate integrity agreement from the government, so I can't really respond in any way to say this is how our behavior could or would change in response to that. But we're not expecting the government to require significant underlying changes to our fundamental operations.

I think they will ask us to sort of strengthen and validate our compliance program, which we're more than prepared to do. But no, I don't think that we anticipate any significant changes to the way we -- the underlying way that we approach this business.

Josh Raskin -- Nephron Research -- Analyst

Got you. That's perfect. And then last quarter, you talked in the acute care side, obviously, the slow start in January, a little better in February, better in March, April, continues to. Anything to point out in terms of the cadence across the quarter and the second quarter? I mean it seems like with a 9% revenue number, I'm guessing broad-based strength across each month.

But just curious if there was any movement intra-quarter.

Steve Filton -- Chief Financial Officer

Yeah. Look, I think it seemed -- and again, given the fact that I think we still struggle to explain that surgical weakness sort of out of the gate in early 2019, it's a little bit hard for us to exactly sort of describe what was going on. But it seem like that surgical volume and surgical acuity in particular just continued to strengthen as the first six months went on. And to the point where I think we're now back to -- after six months, feeling that we're at a much more normalized level.

And again, I think if you look at our six-month pricing and six-month revenue growth, it seems they're not at all out of line with what our original expectations for the year were.

Josh Raskin -- Nephron Research -- Analyst

Thanks.

Operator

Your next question comes from the line of Frank Morgan with RBC Capital. Please go ahead.

Frank Morgan -- RBC Capital Markets -- Analyst

Good morning. I guess hopping over to the behavioral side of the business. You talked about volume trends. But just curious, any updates that you may have around the rate environment, particularly any kind of states that did midyear updates and their rates?  And then my other question is just an update on your health plan business and DSH payments relative to your guidance.

Steve Filton -- Chief Financial Officer

Yeah. I mean so the health plan, I think as we said earlier in the year, is operating at close to breakeven. That's pretty much what our expectations were, and I think we have every expectation that's the way we'll finish the year. And so we're pleased with that turnaround over the last couple of years.

And with -- as that business operates at a breakeven and adds value to our markets in other ways, I think it's much closer filling our original intents for that business. I think our DSH numbers are coming in fairly close. You'll see when we publish the Q, we give that detail, but I think they're coming pretty close to what are expectations were. And then as far as rates go, Frank, again when I look at sort of where we are for the six months in terms of revenue per unit, I think on the acute side, we're in sort of a 1 to 2% range.

That's a little bit lower, but I think that's kind of a function of sort of higher volumes. I would guess that as the year goes on, volumes will come down a little bit and rates will come up a little bit. Our rates on the behavioral side in the sort of the 2.5% range, I think, are pretty consistent with what our expectations were. So I don't think there have been any kind of midyear rate changes either by government or commercial entities that significantly changed our outlook.

Frank Morgan -- RBC Capital Markets -- Analyst

Thank you

Operator

Your next question comes from the line of Ralph Giacobbe with Citi. Please go ahead, Mr. Giacobbe. Your next question comes from the line of Kevin Fischbeck with Bank of America.

Please go ahead.

Kevin Fischbeck -- Bank of America Merrill Lynch -- Analyst

Great. Thanks. Yes. So I wanted to go to the behavioral business.

I think I kind of conceptually understand the comment that when length of stay drop, then it gives more room for admissions to increase and vice versa. So there's some interplay there. But that almost kind of implies that there's some sort of capacity constraint at the company to have the need that -- to have that trade-off either from a bed perspective or from a staffing perspective. Why is it that we can't see both happen at the same time? Do you feel like that you need to add more beds? Or are there still some staffing shortage that's kind of acting as an offset?

Steve Filton -- Chief Financial Officer

Yeah. And I didn't mean to imply, Kevin, that that's sort of the only dynamic and that effectively we can't drive revenue any higher under our existing capacity. And I think you're correct when you described sort of the potential capacity constraints as being both physical beds and labor. But I think in some of the facilities, that's the case.

And I do think if you go back and you look at length of stay and admissions for an extended period of time, you will see some of the interplay that I've talked about. Having said that, there is no question that our volume growth is still a little bit lower than how we'd like it to be and that we were expecting. I guess the two places that I would point to in the quarter, one, sort of obvious and just mechanical, we continue to have this facility in Panama City, Florida, which was closed in the fourth quarter of last year due to a hurricane. Reopened some time during the second quarter, but significantly down both revenue and volume-wise in Q2.

Hopefully by Q3, that will largely start to wash itself out. The other issue, which I know we've mentioned at least in the last couple of calls, is that the addiction treatment business continues to struggle, again both from a volume and a revenue perspective. And that sort of provides some unfavorable movement of the needle on volumes that has nothing to do with capacity or the issues that we discussed in your question earlier.

Kevin Fischbeck -- Bank of America Merrill Lynch -- Analyst

So I guess what is causing the addiction treatment center issues? And when do you think you can get those resolved?

Steve Filton -- Chief Financial Officer

Yeah. Look, I think it's a bit of a complicated dynamic, but it's mostly payer-driven. I think payers are doing a couple of things. I mean, one, they're clearly moving away from the out-of-network model that many providers sort of relied on.

We relied on in part. It was not our exclusive model. But as our patients move from out-of-network to in network, generally, the reimbursement rates are going down. And I think payers are also looking for non-inpatient alternatives to addiction treatment, and we're seeing the impact of that as well.

We continue to work on that business. We've seen some sequential improvement from Q1 to Q2. But again, I mean if I would point to a particular segment of the behavioral business that is driving that volume weakness, this would be it.

Kevin Fischbeck -- Bank of America Merrill Lynch -- Analyst

And then maybe just last question. And you touched on it maybe a little bit in the past two answers, but you mentioned that you don't really view the investigations as being a huge overhang from a volume perspective or growth perspective. But then separately, you talked about how you do expect revenue to be growing or to accelerating in the psych business in the future. So what exactly do you think is going to be the biggest driver to that growth?

Steve Filton -- Chief Financial Officer

Well, and again, those to me are just two discrete statements. I think we have said all along that our confidence that the volumes in the business would grow is that our own internal data suggests that there's -- remains a significant amount of unmet demand and a significant amount of what we describe as deflections, patients who we are unable to admit at various times because of different reasons. Again, and you touched on some of them, a lack of a physical bed, a lack of sufficient clinical staff, sort of clinical criteria, the inability to treat a particular diagnosis, et cetera. And I think we are working and have been working over the last several years on those issues.

We have clearly made progress. I mean the revenue growth in our behavioral division is much higher in 2019 than it was back in 2015 and 2016. We are the first who can see that improvement comes lower than we expected. But what has always reinforced our fundamental bullishness is this idea that there is a significant amount of unmet demand out there, and that the demand sort of dynamic and the demand equation has not really changed in any basic way since the business slowed three or four years ago.

Kevin Fischbeck -- Bank of America Merrill Lynch -- Analyst

So when you say, Steven, working to address those issues is that you're spending more on capex or that you're hiring more nurses? What exactly is the driver to address those issues?

Steve Filton -- Chief Financial Officer

Yeah. No, I think it's a multitude of issues and I think all of which we've discussed over the course of the last few years. We've added more beds. We've clearly added more personnel and really focused on recruitment and retention over the last several years.

And I think that improved that situation, and we've addressed the issue of our ability to treat a broader array of patients, particularly patients with more acute or more complicated illnesses, and in particular, sometimes, comorbid medical surgical illnesses.

Kevin Fischbeck -- Bank of America Merrill Lynch -- Analyst

Thank you.

Operator

Your next question comes from the line of Ralph Giacobbe with Citi. Please go ahead.

Ralph Giacobbe -- Citi -- Analyst

Thanks. Good morning. Can you hear me?

Steve Filton -- Chief Financial Officer

I can hear you, Ralph.

Ralph Giacobbe -- Citi -- Analyst

OK. I was hoping you can give a little more of a sense of payer mix and/or volume trends in each of the commercial Medicaid and Medicare buckets, if there was sort of any acceleration from baseline or more pronounced move in any of those categories specifically within the surgical comeback.

Steve Filton -- Chief Financial Officer

No. Look, Ralph, I think we made the point in Q1 that the surgical weakness and that unfavorable shift from surgical to medical was not really payer-related but seemed to be relatively broad-based and almost by definition or maybe not by definition, but the improvement has not been, I think, payer-based. Our payer mix, I think, has been fairly consistent for a number of years now. Medicare -- on the acute side, in particular, Medicare is probably our fastest-growing payer.

Medicaid follows that. Commercial is probably growing at a slightly slower rate but still a positive rate. And uninsured rates have been generally the same. The only other kind of payer mix issue that I'd point out certainly not unique to us but among our commercial population, we certainly see a greater portion of the patient of the bill, the overall hospital bill due from the patient.

And we've tried to modify our collection processes and procedures to address that. And again, we're certainly not unique in that. That's a phenomena that, I think, every healthcare provider has experienced over the last several years.

Ralph Giacobbe -- Citi -- Analyst

OK. That's helpful. And then you have some volatility within the acute care staff, particularly around sort of the components of revenue with periods of outsized volume and pricing stats. I know in the past you've talked about the dynamic around the observation stage.

I can't help but notice a big admission number for some of the quarter and year to date. Just want to flesh out, is there any of that observation noise still at play here? Or anything else to call out perhaps driving the optics of the stat that kind of makes up the overall revenue?

Steve Filton -- Chief Financial Officer

I don't think so. I mean I will say certainly, as we -- when we talk to our operators, this issue of observation versus admission is an ongoing issue at this point, really, with our commercial payers. So again, it's an ongoing issue that we're constantly addressing. We've devoted a significant amount of both internal and external resources to the proper classification of patients and making sure that we get paid appropriately from our payers.

But I don't think, to your question, it's really influencing the upticks of admission growth. In fact, I don't think we're seeing significant changes back and forth.

Ralph Giacobbe -- Citi -- Analyst

OK thank you.

Operator

Your next question comes from the line of Pito Chickering with Deutsche Bank. Please go ahead.

Pito Chickering -- Deutsche Bank -- Analyst

Good morning, guys. Following up on the share repurchase questions. I understand that doing M&A is a priority for the company. But if there are no deals, is there a minimum leverage ratio that you guys can sort of guide us to? So if there's no large deals, should we think of you guys running between 2.5 and three times of leverage and adjusted share repo? Or is that the right way of thinking about it?

Steve Filton -- Chief Financial Officer

Yeah. Pito, look, again, we're not going to commit to a specific leverage ratio on the call today or, frankly, at any point. I think we like to maintain flexibility. But we acknowledge that our current leverage ratio is, well, probably relatively inefficient.

And -- but it leaves us a tremendous amount of flexibility to become a more active return of capital to shareholders, which I think will drive the signal in a couple of ways that we would be in today's or yesterday's press release. But also, we have the flexibility to respond to other opportunities that, frankly, we may or may not be even be contemplating today as we move forward. And so we're going to continue to do that. But I think the obvious sort of statement is we certainly operated the company at higher leverage levels than we're at today for the right sort of deals and the right sort of investments back in the mid-2000 period, which may be a long time for investors.

But for many of the members of the management, it's not so long ago. We bought back probably over two or three-year period maybe 20% of the outstanding shares of the company. We're happy to do so. It made sense at the time.

And if that sort of an opportunity to present itself in the future, so be it.

Pito Chickering -- Deutsche Bank -- Analyst

OK. I mean just to sort of, I guess, ask it in different way. If you guys are running at three turns of leverage with just share repo, are there any deals that you've seen on the last five years you guys couldn't complete by going from that leverage to higher multiples?

Steve Filton -- Chief Financial Officer

Yeah. I mean, look, one of the things about M&A it's difficult to answer because we're not going to get into specifics of deals that we've looked at and contemplated and what their size was, etc. But look, your basic question, Pito, I think is fair and maybe commentary. We have a lot of financial flexibility given our capital structure.

We acknowledge that. We like that. And we think that if that flexibility has allowed us over the last many years to respond to opportunities as they arose and to be judicious employers or deployers of capital, and I think we continue to view ourselves that way.

Pito Chickering -- Deutsche Bank -- Analyst

OK. And then one last quick follow-up here. We've obviously seen the key trends have evolved over the last six months. As you look at the cadence of admissions during Q2, do you plan to making any changes to staffing going to third quarter? Or are you assume that things will normalize in the back half of the year from a staffing perspective?

Steve Filton -- Chief Financial Officer

It's a great question. And honestly, it's an everyday challenge for hospital operators. As their volume goes up, they have to decide whether it is kind of occurring an increase that necessitates more permanent hires or whether it's a more temporary sort of an increase of that is better served by either over time or temporary nurses and registry nurses, et cetera. So honestly, I think we're making that judgment in each market depending on what's happening in that market, etc.

Look, I think it's fair to say that UHS' acute care volume strength is not something that's terribly new over the last several years. And quite frankly, maybe from periods even much longer than that, our acute care volumes have generally been sort of industry-leading and ahead of our peers. So again, I do think we think about our volume growth as that sort of above average volume growth and sort of more of the norm for us. Although again, as I mentioned earlier, I'm not sure that 5% is likely to persist.

That would be an extraordinary level of volume growth to see over an extended period of time.

Pito Chickering -- Deutsche Bank -- Analyst

Thanks so much.

Operator

Your next question comes from the line of Steven Valiquette with Barclays. Please go ahead.

Steven Valiquette -- Barclays -- Analyst

Thanks. Good morning, Steve and Alan. Congrats on the strong results. OK.

I guess just for us, there's been some continued ebb and flow in Washington this year just around the push for greater transparency and hospital pricing and actually healthcare pricing overall. I guess I'm just curious if you have any updated thoughts around this topic from the UHS point of view.

Steve Filton -- Chief Financial Officer

Look, I think, Steve, the transparency tends to focus on two things. One is transparency for the individual patient who does not have insurance or has a significant self-pay portion of insurance that is trying to negotiate a particular rate. Honestly, I think that affects a relatively small percentage of the population and a small percentage of the procedures. Health care is complicated, and sometimes it's not always easy to just say, look, I'm having gallbladder surgery.

I want to know exactly what it's going to cost. That may be a difficult exercise for an individual patient. The other dynamic, which seems to be the focus of at least some legislators, is this idea that there ought to be complete transparency of the rates paid between private insurers and private hospitals. Whether that is a concept that really will get traction and also prove to be legal, et cetera, I'm not sure.

But at the end of the day, I believe that the broad outlines of that sort of pricing landscape are out there. I used the sort of easy example that if we've got a payer who is our -- the No.1 payer in the market and it becomes public knowledge that the rates that we accept from that payer are the lowest in the market, to me that's not a surprise. It's not a surprise to us. It's not a surprise to the payers in the market.

And if a much smaller payer comes to us and says, "Well, now that I know that you accept much lower rates from this payer, we want you to accept the same rates from us." We're just not going to do it, and no one is going to be able to force us to do that unless the government decides that they're just going to set prices all around. And I don't think it's going to be the case. So I don't think we view transparency as something that will change our everyday business practices by a great deal.

Steven Valiquette -- Barclays -- Analyst

OK. I appreciate the color. Thanks.

Operator

Your next question comes from the line of Peter Costa with Wells Fargo. Please go ahead.

Peter Costa -- Wells Fargo Securities -- Analyst

Thanks and congratulations on the quarter. I had a couple of questions, somewhat unrelated. The first one related to the acute care business. I appreciate your view of looking at it sort of over a six-month period.

But within that period, it sounds like there's a little bit of a difference in the second quarter of improvement between McAllen and maybe Denison as well. And I'm wondering if you can scale those improvements for us. And then perhaps, where are we in terms of how much further there is to improve in those two markets?

Steve Filton -- Chief Financial Officer

Yeah. I mean I think that's difficult to do, Peter. I think what I was suggesting is that earlier in Q1, there was a lot of focus on this idea that some people felt like the ramp for the balance of the year was aggressive or more dramatic than they imagined, et cetera. And we simply suggested that the cumulative effect of these sort of mid-sized capital projects was something that we thought was helping this ramp as the year went on.

And that we were making the point, I think, or I was making the point that because it was not a whole hospital project like a Henderson or a Temecula from several years ago, we tend not to talk about these individual projects. And therefore, I cited that I thought it's a potential disconnect between our own internal model and the Street model. Look, at the end of the day, sort of our guidance is our guidance. And I think it suggests too -- not just suggests, it very explicitly says that to the Street, this is what we expect our earnings power to be for the balance of the year, and our guidance remains unchanged.

And I would just broadly say we continue to have confidence in our full-year guidance.  Obviously, we sort of never really get into what's the Texoma emergency room impact likely to have. I just don't think quite frankly that that's a terribly productive conversation when you get to that granular level of detail.

Peter Costa -- Wells Fargo Securities -- Analyst

OK. That's helpful. And then second question, this is more on the behavioral side. Now you've commented to the change in management there, and I'm wondering if you've seen any outmigration either of clinical staff or facility level management or referral sources to Acadia since Debbie went away.

Steve Filton -- Chief Financial Officer

No. Look, I think that Debbie has talked about it. We've acknowledged that a handful of personnel have moved over. I don't think that's a terribly significant surprise when somebody of that level and somebody of that tenure moves.

But I think we're very comfortable with the staff that remains here. We've got a very deep and long-tenured and hard-working bench that we're quite pleased with and feel like when we fill that top slot, it'll really just sort of round out our approach. As far as sort of other the other issue of referral sources and payer behavior or whatever in market, I would say we've seen no impact whatsoever. And again, I would -- I'm not surprised that that -- those markets tend to operate very independently.

Those clinicians think of themselves as the employees of X, Y, Z hospital rather than sort of a broader corporate entity. And we frankly encourage that. So we really see none of that at the detailed operating level.

Peter Costa -- Wells Fargo Securities -- Analyst

And then just lastly, from a leadership position, where are you in that process at this point? And do you think we're getting closer to the end of finding somebody?

Steve Filton -- Chief Financial Officer

Yeah. When we undertook the process based on there, it's been a long time since we filled that particular behavioral position. But we filled the comparable acute division a few times over the last few decades, and it's generally been eight, nine-month, 10-month process. We're starting to get toward the end of that.

And I think we feel like the original estimates at time were about right in that I'm not going to set an exact date. But I would think some time within that range or close to it, we should have a very capable person sitting in that seat.

Peter Costa -- Wells Fargo Securities -- Analyst

Thank you very much.

Operator

Your next question comes from the line of Whit Mayo with UBS. Please go ahead.

Whit Mayo -- UBS -- Analyst

Hey, thanks. Just wanted to follow up on that last question just as it kind of relates to leadership. Is there anything strategically maybe that you're doing differently now in the behavioral business? Are we going to be talking about any new initiatives a year from now, any investments? Just wondering like what actually has changed like at the local field level in that division and what we should expect to see in terms of changes in terms of initiatives and strategy going forward.

Steve Filton -- Chief Financial Officer

So look, I think we have talked a number of times about the fact that we're trying to use -- I mentioned before that it's been a long time since we've changed this top position in the behavioral segment, and so I think we would like to use the opportunity to at least reevaluate a potential sort of strategic reset and not, I think kind of a complete overhaul of the business. So I think we have a very successful business.  But as we think about new technologies and things like telemedicine, the use of telemedicine in the behavioral space or how the behavioral slice of the business interacts with the broader population management initiatives that we see in healthcare, I think probably, to your point as you framed the question, a year from now, I would guess that we may be talking about those dynamics more than we had in the past. And then I think we're hoping that the opportunity to hire a new person with some different experience, et cetera, will allow us to engage maybe more productively in those conversations.

Whit Mayo -- UBS -- Analyst

OK. I guess we'll stay tuned there. I wanted to go back maybe for a second just on Pito's question around staffing. We're now about -- we're at 4% unemployment, wherever we are.

I think most investors, at least in my conversations, really struggle to see how acute care hospitals aren't seeing more pressure around staffing cost. And what are you seeing and how do you address the question? And maybe if you could comment more specifically on contract labor and professional fees. Obviously, the physician staffing companies are under some level of stress at this point. So I wonder if you're seeing more ask around subsidies.

Any comments would be helpful.

Steve Filton -- Chief Financial Officer

Sure. Look, Whit, I think broadly, your comments are fair. Finding a sufficient number of qualified clinical personnel in -- frankly in either business segment, whether that's nurses or doctors, is definitely challenging. And a very significant portion of our operator's efforts I think are focused on recruitment and retention again of qualified clinical personnel, whether that's nurses or doctors.

Look, the issue -- and yes, when you talk about it, when you sort of look at 4% unemployment, how are we not more challenged? And I think we -- are challenged. But this is always one of those things where we don't have to outperform 99% of the universe. We just have to outperform our local competitors who are basically -- who we're competing for, for that -- for those clinical personnel. And so we work very hard at recruitment and retention policies that allow us to do that.

It's a big focus, and I think our flexibility, our willingness to be creative, et cetera, helps us in that endeavor. But it's absolutely a challenge. And look, I think one of the reasons why the two businesses appear not to have as much cost pressure as you might expect is we saw a lot of that cost pressure two or three years ago. Frankly, I think as a company, we talked about it a lot more in 2015 and '16 than many of our peers.

I don't know if that's because we were feeling it sooner in our markets or just because maybe we were being more realistic about the impacts of it. But I think to a degree, what we're seeing now two or three years later is that those pressures, at least as they're reflected in the financial statements, have anniversary-ed themselves and have largely sort of stabilized.

Whit Mayo -- UBS -- Analyst

Can you comment maybe on professional fees and the question around the physician staffing company's subsidies? Any color will be helpful.

Steve Filton -- Chief Financial Officer

Yeah. I think other than anecdotally, I mean, look, I could take off three or four examples throughout our portfolio where we've seen some pressure from our contract physician providers for increased subsidies or fees or whatever it might be. But I don't think that overall -- and I have said, a few people have asked about our other operating expenses over the last several years. And I think a little bit of a tick up in that, on that line is some of that pressure.

But I don't think it's really enormously needle-moving in terms of really keeping margins suppressed or anything like that.

Whit Mayo -- UBS -- Analyst

Great. Thanks.

Operator

Your next question comes from the line of Gary Taylor with JP Morgan. Please go ahead.

Gary Taylor -- J.P. Morgan -- Analyst

Hi, good morning. Just a few quick questions. First, Steve, you had mentioned the ongoing DOJ investigation costs were about 10 million or so annually that would go away as this closes. Do you anticipate any measurable costs from complying with the CIA that you're going to have to sign? It seems like other companies might point to a couple of million dollars or so associated with that.

But I want to get your thoughts.

Steve Filton -- Chief Financial Officer

Yeah. So again, I think we're trying to be clear. We've seen nothing specific from the government. So it would be difficult for us to kind of frame what the costs could or should be.

But I guess, and maybe I should have been a little bit clearer than this, I mean I think that the relief of those legal fees at a minimum should help to fund whatever that incremental cost might be.

Gary Taylor -- J.P. Morgan -- Analyst

Right. And then I maybe just missed the tailwind of your response to Frank's question. I didn't catch if you asked that explicitly. But was there anything to call out in the acute EBITDA this quarter in terms of just supplemental payments -- extra supplemental payments or something that we might see in the Q?

Steve Filton -- Chief Financial Officer

I don't think anything material.

Gary Taylor -- J.P. Morgan -- Analyst

OK. And my last one. Maybe this is one more for Alan, if he's still listening. Just thinking about Intermountain acquiring HealthCare Partners Nevada, and just what are the implications of that? Do you think that's a precursor to them wanting to get into the Vegas hospital market? How much would you care about that? Any thoughts would be interesting.

Steve Filton -- Chief Financial Officer

Yeah. I mean I'll answer this. It's something we've routinely discussed here. So I think we're of the same mind.

Look, I think the good news, as this process unfolded, we had concerns that United would be able to keep this business, and I think that would have created a real competitive advantage for them. So when the FTC required them to sell this business, I think that we view that as a favorable development. I guess ideally, we would have liked for the business to be sold to a payer who had no real presence in the market. That would have been sort of perfect from our perspective.

But the fact is the business has been sold to a provider who doesn't really have much of a presence in the market. I think it's kind of maybe the next best thing. Look, I think it's a signal, as you sort of alluded to in your question, that over time, Intermountain probably will either has plans or will execute plans to develop some sort of provider presence in the market. But obviously, that will take some time, and they will have some obstacles to overcome in a market that is sort of well entrenched among a small number of providers.

So we face sort of competitive dynamics in all of our markets. This will be a new one in Las Vegas, but it's not one that at the moment we're losing sleep over. Although to be fair, we're focused on it, and we're prepared to respond to it.

Gary Taylor -- J.P. Morgan -- Analyst

Thank you very much.

Operator

Your next question comes from the line of John Ransom with Raymond James. John, your line is open.

John Ransom -- Raymond James -- Analyst

Hi, good morning. This is sort of an in the leads question, and I don't mean to imply that it's material short term. But we have heard in behavioral that the payers are starting -- the managed care payers are starting to layer in some outcomes type of penalties, for example, readmissions within a certain time frame. And so my question is, are you seeing that, No.1? And then No.2, do you think anywhere in our lifetime we're going to see any meaningful type of quality outcomes data in behavioral, which certainly has lagged this in acute by a decade or more? But just curious to see if this is a way of raising the bar and if there's anything to this.

Steve Filton -- Chief Financial Officer

Yeah. So I'll go in reverse order, John. I mean certainly, your comment is accurate. The sophistication and the maturity of quality reporting and outcomes reporting in the behavioral segment certainly lags the acute care, med-surg segment and maybe other service lines as well.

But I think UHS has sort of been on the cutting-edge. We have worked directly with the joint commission, as an example, to develop more standardized quality and outcomes reporting. I think we do more in that area than just about anybody else in the space. But I agree with you, we are probably several years behind where the med-surg industry is.

As far as the sort of specific dynamic of payers having sort of readmission penalties, I don't think we've seen that. I also find it a little bit incongruous in an environment where payers are, at least in our own minds, aggressively and in some cases arbitrarily insisting on shorter length of stay and earlier discharges of patients where the payers tend to come back and suggest that we should than bear a penalty because those patients have been readmitted when we thought they were prematurely discharge. We would struggle with that. So we've not seen that in anything in sort of material or measurable way.

John Ransom -- Raymond James -- Analyst

So just what is the benchmarking for quality? What is being measured? And do you even have electronic medical records yet in behavioral? Is it just some qualitative reporting? Is there anything that's being measured at this point?

Steve Filton -- Chief Financial Officer

Yeah. Look, I think things like use of restraints and frequency of restraints, outcomes measurements are vastly being measured. And it's probably too complicated. And by the way, I'm probably not the best person as a nonclinical person to be able to address it.

But happy off-line to share more of that detail.

John Ransom -- Raymond James -- Analyst

Thank you.

Operator

Gentlemen, your final question comes from the line of Steve Tanal with Goldman Sachs. Your line is open.

Steve Tanal -- Goldman Sachs -- Analyst

Hey, good morning, Steve. Thanks for taking the question. Yes. So I just wanted to clarify first on this commentary before.

You said tracking in line with guidance. I think guidance is for DSH to be down or Medicaid supplemental payments to be down 30 million year on year in '19. And so just wanted to understand, is that sort of still the latest thinking? Is that what you're tracking to? And maybe anything to note at the cadence there?

Steve Filton -- Chief Financial Officer

Yeah. I mean I think as we've disclosed in the first quarter, it's a little bit less than that. The decline is not as great. But I don't think in the second quarter, the trajectory changed a great deal from where -- what our first-quarter Q at.

Steve Tanal -- Goldman Sachs -- Analyst

Got it. OK. And maybe just one on the behavioral side then as well. So noticing same facility earnings were higher than noncomp -- or sorry, higher than total.

And so like the noncomp facility seemed to have lost about 7 million in the quarter. I'm just sort of thinking about what's in that bucket. I think Danshell has followed. There's 25 hospitals, but it looks like there's 39 just the way you guys reported.

So maybe Panama City is another one. But can you remind us sort of what else may be in there? And then how Danshell did in the quarter?

Steve Filton -- Chief Financial Officer

Yeah. So Danshell is tracking pretty much. I think when we acquired them, they had about a $10 million annual EBITDA stream. And I think they are tracking something close to that quarterly, obviously.

I think in terms of the, otherwise, the non-same store, I know we had -- Florida has eliminated their CON. And we had, I think a $3 million write-off versus all of our behavioral fill-in assets. I know that meant non-same-store number. I can't think of anything else terribly material in that number for the quarter.

Steve Tanal -- Goldman Sachs -- Analyst

Got it. Perfect. So then just maybe bigger picture, thinking Danshell and U.K. Can you give us your thoughts on how that business is doing? And maybe your level of interest of potentially growing the U.K.

business on the behavioral side?

Steve Filton -- Chief Financial Officer

Yeah. I mean, look, I think that Danshell is sort of reflective of the way that we envision growing the U.K. It was a small, again, $100-million-or-so acquisition. And I think we are looking for those sort of one-off, either development opportunities, we've done a few de novo developments.

We've had invest to a number of facilities in the U.K. We've done a few smaller acquisitions like Danshell and a company called Alpha. But I think other than that, it's not like we're looking to increase the size of our footprint in the U.K. by multiple times.

That's not our intent.

Steve Tanal -- Goldman Sachs -- Analyst

Got it. That's helpful. Thanks a lot.

Operator

This concludes our question-and-answer session. I'll turn the call back over to the presenters for closing remarks.

Steve Filton -- Chief Financial Officer

OK. We just thank everybody for their time and look forward to speaking with everyone again next quarter.

Operator

[Operator signoff]

Duration: 67 minutes

Call participants:

Steve Filton -- Chief Financial Officer

A.J. Rice -- Credit Suisse -- Analyst

Alan Miller -- Chief Executive Officer

Matt Borsch -- BMO Capital Markets -- Analyst

Justin Lake -- Wolfe Research -- Analyst

Sarah James -- Piper Jaffray -- Analyst

Josh Raskin -- Nephron Research -- Analyst

Frank Morgan -- RBC Capital Markets -- Analyst

Kevin Fischbeck -- Bank of America Merrill Lynch -- Analyst

Ralph Giacobbe -- Citi -- Analyst

Pito Chickering -- Deutsche Bank -- Analyst

Steven Valiquette -- Barclays -- Analyst

Peter Costa -- Wells Fargo Securities -- Analyst

Whit Mayo -- UBS -- Analyst

Gary Taylor -- J.P. Morgan -- Analyst

John Ransom -- Raymond James -- Analyst

Steve Tanal -- Goldman Sachs -- Analyst

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