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F500-2021-270-Universal Health Service

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Universal Health Services is one of the largest providers of hospitals and health care services in the U.S. Since its founding in 1979, the health care giant operates more than 400 acute-care hospitals, behavioral health facilities, emergency departments, and ambulatory surgery centers across the U.S. and the United Kingdom. Universal Health Services also offers an insurance plan, the Prominence Health Plan, including Medicare Advantage plans for members in Florida, Nevada, and Texas. The company served over 3.5 million patients in 2024, operating with nearly 100,000 employees globally. In 2024, the company was ranked by Fortune as one of the World’s Most Admired Companies.

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Universal Health Services (UHS): Company Profile, Stock Price, News, Rankings

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Universal Health Services

universal health services

Good day and thank you for standing by. Welcome to the Fourth Quarter twenty twenty four Universal Health Services Earnings Conference Call. At this time, all participants are in a listen only mode. After the speakers' presentation, there will be a question and answer Please be advised, today's conference is being recorded. I would now like to hand the conference over to your speaker today, Steve Filton, Executive Vice President and CFO.

Thank you, and good morning. Mark Miller is also joining us this morning. We welcome you to this review of Universal Health Services' results for the fourth quarter ended 12/31/2024. During the conference call, we'll be using words such as believes, expects, anticipates, estimates and similar words that represent forecast 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 ks for the year ended 12/31/2024.

We'd like to highlight certain developments and business trends before opening the call up to questions. As discussed in our press release last night, the company reported net income attributable to UHS per diluted share of $4.96 for the fourth quarter of twenty twenty four. After adjusting for the impact of the items reflected in the supplemental schedule included with the press release, our adjusted net income attributable to UHS per diluted share was $4.92 for the quarter ended 12/31/2024.

During the fourth quarter of twenty twenty four, on a same facility basis, adjusted admissions to our acute care hospitals increased 2.2% over fourth quarter of prior year. Same facility net revenues in our acute care hospital segment increased by 8.7% during the fourth quarter of twenty twenty four as compared to last year's fourth quarter, driven primarily by a 5.3% increase in net revenue per adjusted admission. Meanwhile, operating expenses continue to be well managed. The amount of premium pay in the quarter, for example, which declined from a peak of $153,000,000 for the first quarter of twenty twenty two was $60,000,000 in the fourth quarter of twenty twenty four, remaining consistent with the previous two quarters. For the full year of 2024, our strong acute care revenues combined with effective expense controls resulted

a 13% increase in EBITDA even after excluding the growth in Medicaid supplemental payments. During the fourth quarter, same facility revenues at our behavioral health hospitals increased by 11.1, driven primarily by an 8.7% increase in revenue per adjusted patient day. Excluding the year over year growth in Medicaid supplemental payments, the same facility revenue increased with 7.4%.

Included in our operating results during the fourth quarter of twenty twenty four were aggregate net incremental reimbursements of approximately $50,000,000 recorded in connection with various state supplemental Medicaid programs, including $31,000,000 of additional net reimbursements from the Nevada State Directed Payment Program covering the six month period of 07/01/2024, through 12/31/2024. These net reimbursements were more than the supplemental program projections included in our earnings guidance for the full year of 2024 as revised on 07/24/2024. As a result of unfavorable trends experienced during the past several years during the fourth quarter of twenty twenty four, we recorded a $35,000,000 increase to our reserves for self insured professional and general liability claims. Our operating results for the full year of 2024 included a $79,000,000 increase to our self insured professional and liability reserves. Our cash generated from operating activities was $658,000,000 during the fourth quarter of twenty twenty four as compared to $452,000,000 during the same quarter in 2023 and $2,067,000,000 during the full year of 2024 as compared to $1,268,000,000 during 2023.

We spent $944,000,000 on capital expenditures during 2024, which was consistent with our original forecast for the year. In our acute division, we opened West Henderson Hospital in Las Vegas late in 2024 and plan to open Cedar Hill Medical Center in Washington, D. C. In the next few months. We forecast that these facilities will be EBITDA positive in 2025 on a combined basis.

In both of our segments, we continue to invest in expansion of our outpatient presence and the broadening of our continuum of care. For the full year of 2024, we acquired $599,000,000 of our own shares pursuant to our share repurchase program. Since 01/01/2019, we have repurchased more than 29,200,000 shares, representing approximately 32% of our shares outstanding as of that date. As of 12/31/2024, we had $1,170,000,000 of aggregate available borrowing capacity pursuant to our $1,300,000,000 revolving credit facility.

The core operating assumptions underlying our 2025 operating results forecast, which was provided in last night's release, largely reflect the historical trends in the respective businesses with EBITDA growth in the mid single digits. We expect continued improvement in salary and wages and general cost trends that will remain largely stable in 2025. As noted in our 10 ks filed yesterday, our 2025 operating results forecast excludes any supplemental Medicaid revenues in Tennessee and the District Of Columbia, pending CMS's approval of those programs. As the 10 ks schedule reflects, our 2025 forecast assumes total consolidated Medicaid supplemental payments will decrease slightly as compared to 2024. We believe demand for our behavioral services remains solid and our same facility adjusted patient day growth in 2025 at our facilities located in The U.

S. Is forecasted to be in the 2.5% to 3% range. We've accelerated technology investments in our behavioral hospitals to improve patient care, including electronic health record implementations and expanded use of patient monitoring automation. We acknowledge that the current political environment has created a level of uncertainty, especially as it relates to ongoing Medicaid reimbursement. Our 2025 forecast is based on current Medicaid reimbursement projections in connection with various programs that could be subject to change.

In our acute business segment, we are pleased that 80% of our hospitals currently have an A or BUE drug rating, well above the national average. And in our behavioral division, we saw meaningfully significant improvement in patient experience scores in 2024. We are focusing on continued improvement of these metrics in 2025. We are now pleased to answer your questions.

Our first question comes from Andrew Mok with Barclays. Your line is open.

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

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

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

Great. And then maybe just a follow-up. The guidance range, I think, is $127,000,000 wide, which is higher than previous years despite better operations and visibility. So why is the range of outcomes here wider than usual? And where are the puts and takes within that range?

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

One moment for our next question. Our next question comes from Ben Hendricks with RBC Capital Markets. Your line is open.

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

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

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

Yes. So, I think it's worth noting that in establishing our malpractice reserves, we use a third party actuary who evaluates our claims history, pending claims, industry trends, etcetera. It's a relatively comprehensive analysis. Historically, we've tried to set and establish our reserves sort of at the midpoint of the range that our third party actually provides to us. Given some of the volatility in that area and some of the pressure, we tried this year to move a little bit towards the higher end of the range.

So we are hoping that there is an element of conservatism built into those reserves and that there won't be a need for another uptick in 2025. Obviously, you can't be assured of that, but we feel like we've taken a pretty prudent position here.

One moment for our next question. Our next question comes from Anne Hynes with Mizuho. Your line is open.

Hi, good morning. Thank you. Can we talk about behavioral same store patient days? I remember thinking and maybe I'm remembering incorrectly that you thought you would be exiting 2024 at about 3%, which I believe it was below 2%. So what was the driver of that?

And I think you said in guidance, you assume it's going to accelerate to 2.5% to 3%. Can you just tell us what the drivers of that acceleration

Yes. So and in fact, Ann, I think for the first two thirds of the quarter, October, November, we were tracking sort of in that 2.5% range and feel pretty good about things. I remember and honestly, probably my last public appearance was at your conference in early December. And I remember telling people that I thought we were doing well, except it was always hard to predict what would happen in the back half December with the holidays.

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

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

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

Yes. I mean, so what's built into our guidance for 2025 is, I would say, same store behavioral revenue growth in the 6%, seven %, eight % range. And again, I think that's sort of 2.5% to 3% volume and 3% to 4% price. To be fair, that 3% to 4% and that 3% to four percent price is exclusive of any changes in supplemental payments. That's just what I would describe as core pricing.

Our core pricing, and I think that's sort of the crux of your question, has generally been better than that over the last several years, and we'll continue to press our payers and hope to do better than that. So if there's an element of conservatism in our behavioral projections, it's probably on the pricing side of the equation.

One moment for our next question. Our next question comes from Justin Lake with Wolfe Research. Your line is open.

Thanks. Good morning. Wanted to move over to the policy stuff. Specifically, looks like the bigger ticket items like caps are off the table on Medicaid, some discussion that maybe provider taxes would be a place they would pivot to. I know you sophisticated on this stuff.

What are you hearing there in terms of the appetite to look at provider taxes as an area of savings within this legislation?

Yes. So Justin, I would say and I think you know this. I mean, I think the administration has really made no sort of definitive public statements about provider taxes. The point that we've made and I think our peer companies have made is there appears to be wide support for these provider tax or directed payment programs around the country in a large number of states, including states of all political stripes. And so I think one of the things that we're learning or observing from this debate within Congress over the budget bill is that there is a fair amount of support, again, I think throughout the country for Medicaid programs and protecting Medicaid programs.

There hasn't been a whole lot of discussion specifically about directed payment programs, but we believe that there's a significant amount of political support at the state level for those programs in a great many states.

And I just want to add to what Steve just said there because we're clearly monitoring this very closely, talking off the record with many of the folks, not just in Washington, but in the states. And I think that's a key point. The folks in Congress are hearing from the Governor's offices in many of these states. And like Steve said, it's a bipartisan effort. It's not just the Democratic states, but it's many of the large Republican led states as well.

So that tends to suggest that the pushback is significant. And I think we're in a better position than sometimes what we see on the news.

Great. And then just another question on DPP. I know you've got some dollars potentially coming in D. C, Tennessee. You guys do a great job of giving color on that in your 10 ks.

Looks like you're not projecting that. Anything to read into that for 2025? Like any change in your level of confidence that this stuff comes through at the end

So, we believe that our 2025 forecast reflects our historical practices when it comes to DPP. And that is once a program has been approved and is in place, even though all these programs have to be renewed and reapproved annually, we presume that programs that have been approved historically will continue to be approved and they remain in our guidance. The two programs you referenced, Tennessee and Washington, D. C, are new programs that have only been partially approved. So, for instance, Tennessee, the actual program has been approved and the dollars have been approved for the back half of twenty twenty four, but it still requires CMS approval of the $11.15 Medicaid waiver.

And so, until full approval is granted, we haven't included any of those Tennessee dollars. The DC approval is pending in its entirety. We haven't included any of those dollars either in Q4 or in our 2025 guidance. In both cases, the state or the district hospital associations tell us and tell their constituents that they've not heard anything from CMS suggesting that the programs are problematic in any way in their structure. They expect them to be approved.

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

One moment for our next question. Our next question comes from Pito Chickering with Deutsche Bank. Your line is open.

Hey, good morning guys. Thanks for taking my questions. Leverage is now below two times here. Can you just remind us what your targeted leverage ratios are here? And today, using all of your free cash flow to share repurchases, at what point do you start borrowing to maintain your leverage ratios and using those borrowings to increase your share repurchases?

Thanks, Pito. So I think we have historically operated at a leverage level, generally in sort of the high 2s, approaching three. We're certainly comfortable at a level like that. And I would think that where we would generally target things in the future. I think our guidance for the year presumes that we'll use the bulk of our free cash flow for share repurchase, The possibility that we could lever up and use even more than that, I think, is certainly a real possibility and not something we've decided today.

But again, in our guidance, I think we were reasonably conservative in thinking that our share repurchase levels would be around what they've been in the last several years in that sort of $600,000,000 to $800,000,000 range.

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

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

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

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

We've done any number of things. It's a large portfolio and generally an individual hospital is not material to the portfolio, so we don't necessarily disclose or discuss in detail when we do these things. But it's really that aspect of it. And when you ask sort of what is the rationale for that or what causes that, while we acknowledge or we would agree with your overall comment that I think behavioral demand has been strong during this period, obviously demand for particular services in a particular area, particular reimbursement dynamics, all those things can change in the interim. And we do react to those things and effectively try and look at those facilities that are sort of least efficient, lesser returning and trying to determine whether they have kind of a path to getting sort of more towards the bell curve of performance.

And if they don't, we look for potential exit strategies, which again could be closure, could be sale, could be consolidation, could be retooling. All those things I think are always on the table.

One moment for our next question. Our next question comes from Joanna Gachuk with Bank of America. Your line is open.

Hi, good morning. Thanks so much for taking the questions. I guess first, because I don't know that there I missed it, but yes, thanks for talking about your assumptions for your behavioral segment growth for 2025. But what do you assume for acute revenue growth, volumes versus pricing?

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

Thanks for that. And I guess on wages, because I think the nationwide data on wage growth for nursing kind of showed some acceleration in the late twenty twenty four. Are you seeing that or is it just a function of some comp issue there?

Joanna, I'm sorry. When you said that the national data is showing what? I didn't hear what you said.

Yes, wages, but acceleration slightly. Nothing material, obviously, but like just kind of versus the earlier in 2024, then like somehow the couple of these last months in 2024 kind of showed a little bit higher growth year over year. So I don't know if you're seeing any of that. I mean, it sounds like you're thinking about kind of moderation in wage inflation for 2025. I just want to ask if there was anything that happened in late twenty twenty four that kind of might have changed that view a little bit.

Yes. So again, clearly, we've seen a moderation in wage inflation coming out of the pandemic over the last couple of years. And I would sort of characterize the wage environment as fairly stable. I apologize, I didn't hear you the first time. But I think, like you said, those the national surveys sort of suggest kind of some incremental pressure on wages.

I don't think we're really seeing that doesn't mean that we won't. But it doesn't feel like there's that sort of comprehensive pressure and real significant pressure on wages that we were seeing a couple of years ago. It feels like the wage environment and basically the supply demand environment for labor has stabilized pretty significantly.

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

Got it. Thanks. And if I may just squeeze in a last follow-up on the DPP discussion and how you assume $25 versus $24 So two items there, right? Can you quantify how much was prior period that you recorded in $24 And also because you also said there are some programs that you expect to decline. So is it based in those states particularly those programs are based on enrollment and that's what's happening?

Some of these states are going to have a lower VPP dollars available to them because it's linked to enrollment? Thank you.

So I think if you go back and you look at our transcripts from the first three quarters, in each quarter, we called out how much prior period there might have been. And it strikes me that it was a roughly sort of fifteen million dollars twenty million dollars a quarter. So you can extrapolate that and it's maybe $60,000,000 80 million dollars of non recurring or out of period items that we had in 2024. And as I said to kind of a previous question, I think that's the main driver. There may be some individual programs that are showing sort of slight declines next year.

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

Thanks for that clarification. Appreciate it. Thank you.

One moment for our next question. Our next question comes from Stephen Baxter with Wells Fargo. Your line is open.

Hi, thanks. Just two quick ones. I was hoping the first just in case I might have missed it, but sizing the full year amount that the medical malpractice expense came in above your initial plan and how much of that you assume normalizes and becomes a tailwind to the year over year EBITDA growth? And then just another follow-up on the DPP discussion. I understand fully you're not including twenty twenty five amounts for Tennessee or for Washington, D.

C. At this point pending approval. But how do we think about what percentage of this DPP contribution that's in the guidance still for this year is tied to programs that do need to be renewed at some point this year, so might only have partial year coverage kind of as exists today? Thank you.

Yes. So, as far as malpractice goes, what we said in our prepared remarks was we had $79,000,000 of additional malpractice reserves that we added or recorded above and beyond what we had in our original guidance. And for the most part, I think we don't believe that those expenses recur. And so that contributes to some of the growth that we have in 2025. We think we've been reasonably conservative.

To be fair, that's a volatile area that can change and does change, but we feel like we've been fairly prudent and fairly conservative in general. As far as your DPP question, I think as a previous questioner indicated, we have a significant amount of disclosure about our DPP programs by state. And I'd refer everyone. I know we filed the 10 K last night, so I'm sure people have had a chance to review it in detail. But we literally go through each program, indicate what's been approved, what's not been approved.

I mean, my guesstimate is that probably half of the DPP monies in our forecast roughly have been approved for next year already and probably half have approval still pending.

Thank you. One moment for our next question. Our next question comes from Sarah James with Cantor Fitzgerald. Your line is open.

go back to your strategy around the behavioral portfolio.

little bit about areas that you're looking to expand? Are you guys looking at CTC or methadone clinics? Are you looking at more outpatient? Or is it really still focused on inpatient?

we've said in previous calls, Sarah, and I think this is true really of both segments. But specific to the behavioral business, I think we're looking to build out our continuum of care, and I think either Mark or I mentioned that in our prepared remarks, which I think in behavioral specifically means building out the outpatient continuum. And I think that's reflective of historically building out the outpatient continuum generally meant on our campuses and sort of related to our inpatient programs. So, patients who are discharged as inpatients often require continued follow-up care and often receive that care in our intensive outpatient or partial hospitalization programs. I think we've started to develop more of a presence in freestanding outpatient facilities around the country.

We acknowledge that some people who are receiving outpatient care don't necessarily feel comfortable receiving it on the campus of an inpatient hospital or affiliated with an inpatient hospital. And so we're finding that there is demand for freestanding outpatient care separate and apart from our hospitals. We continue to build out our outpatient capabilities as it relates to both active military and retired military. We have a real specialization in that. We have begun, and again, I think we've talked about this in previous calls, to establish a little bit more of a presence in the opioid disorder space.

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

timeline to materiality of that? So what is the pipeline look like or how fast

Universal Health Services (UHS) Q4 2024 Earnings Call Transcript

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