Ardent Health Partners, LLC Price & Performance (ARDT)

With that, I'll turn the call over to Marty.

Thank you, Dave, and good morning. We appreciate everyone joining on the call and webcast. 2024 was a transformational year for Ardent as we demonstrated strong growth and agility in advancing our strategic objectives while executing upon a number of important milestones along the way. Our mission of caring for people resulted in Arden serving over 1,200,000 unique individuals across our eight markets, adding services and facilities to make healthcare easier for patients to access and receive care.

Last July, we also completed our IPO strengthening our financial position to drive continued growth and innovation. [indiscernible] Today, I'm excited to share several positive updates about the company and its performance. I will provide a comprehensive summary of our fourth quarter and full year financial results, highlight key strategic updates and discuss our outlook for 2025. As we embark on a new year, I want to emphasize that Arden remains steadfast in its commitment delivering exceptional quality and service to our Ardent, while ensuring sustainable long term value for our shareholders. Our strategic framework of market share growth in both inpatient and outpatient services margin expansion and disciplined capital deployment. Delivering against our financial goals and building a track record of performance paramount to the Arden management team. That end, we had a very strong finish to 2024 and have several positive financial and operating items to discuss. To start at a high level, we reported robust fourth quarter results punctuated by year over year revenue growth of 19% and adjusted EBITDA growth of over 200%. For the full year 2024, we grew revenue 10% increased adjusted EBITDA 58% and expanded EBITDA margins two forty basis points to 12.5%.

This marks a great year is testament to the hard work the Ardent team has put in to execute on our strategic priorities.

During 2024, we made considerable progress on our service line optimization initiatives, which expanded capacity to engage in higher acuity We meaningfully enhance supply chain efficiencies, We used AI to improve clinical performance with virtual nursing and advanced bedside monitoring check as well as operationally and optimizing operating room schedules to drive strategic surgical growth. We advanced our ambulatory growth strategy highlighted by the recent acquisition of NextCare Urgent Cares in Oklahoma and New Mexico. This brings a total of 27 new Ardent care centers into the Ardent network in the last year should lead to increased volumes over time. [indiscernible] are also pleased that CMS retroactively approved the new Mexico State Directed Payment Program in November for the period covering the second half of 2024. This approval was a key milestone for the state as it will greatly support the broader provider community's ability serve Medicaid patients in New Mexico with access to high quality care. And I'm proud of the work our team did in collaborating with and supporting the state to help bring the DPP program to fruition. In connection with the New Mexico DPP approval, we reported revenues of $94,000,000 and EBITDA of $65,000,000 in the fourth quarter of twenty twenty four, to reflect the retroactive financial impact for both the third and fourth quarters.

This retroactive benefit was not in our 2024 guidance and accordingly the company significantly exceeded revenue and EBITDA guidance for 2024.

When we exclude these amounts from the reported results, the company delivered financial and operating performance that was either consistent with or favorable to our 2024 guidance which we raised in November in conjunction with the third quarter results. More specifically, excluding the impact of the New Mexico DPP program, 2024 revenue finished near the top end of guidance while net patient service revenue per adjusted admission growth was above the top end of the guidance range. Meanwhile, adjusted admission growth and adjusted EBITDA were both modestly above the 2024 guidance midpoints These are all signs of the underlying strength of our business and the results demonstrate our ability to deliver on our financial projections. Arden's balance sheet also continues to strengthen. During the last quarter's earnings call, we indicated that a lease adjusted net leverage ratio would approach three times at the year end compared to the 3.5 times we reported in the third quarter. We delivered on that and finished the year at 2.9 times at December 31. We have over $550,000,000 of cash on hand and available Collectively, this allows Arden to operate from a position of strength particularly as we assess both inorganic and inorganic growth opportunities.

That front, we're pleased to announce that in early January, the acquisition of 18 Urgent Care clinics across New Mexico and Oklahoma from NextCare Urgent Care. This acquisition significantly expands Arden's ambulatory operations in both Ardent and complements our existing health service access points beyond the main urban area. Prior to the transaction, we had only one urgent care facility across Tulsa and Post acquisition, we will have meaningful share of the Ardent care market in each of those geographies. These are attractive assets with adjusted EBITDA margins in the mid teens. This acquisition fits squarely within our strategic growth initiatives which include the build out of our ambulatory footprint either via M and A or de novo development around our existing hospitals. Patients are increasingly using Ardent care as an access point when there is a backlog at their local primary care office or when they do not have primary care providers. It is becoming our first interaction with many Importantly, we see strategic value in owning urgent care facilities in two ways: First, we reap the economic benefit of owning these higher margin assets on a standalone basis and second, it creates a downstream benefit and incrementally increases volumes at our existing hospitals and clinics.

A proof point to the downstream volume benefit, we saw that 45% of the twenty twenty four patient visits in the six urgent care centers we acquired in East Texas were new to the Arden system. Furthermore, of those new visits, approximately 15% resulted in additional Going forward, we are looking to replicate this type of success as we integrate the NextCare app The broader M and A pipeline remains active and we will continue to evaluate outpatient as well as inpatient opportunities. We will remain financially disciplined both in terms of purchase price and our overall leverage. And we will seek assets where we can deliver synergies and demonstrate accretion over a two to three year horizon. We will also explore joint venture opportunities as part of our inpatient M and A growth strategy as that model has provided Arden differentiated value. We turn to 2025, we are optimistic and expect to deliver another strong year [indiscernible] As you saw in yesterday's press release, we issued 2025 financial guidance including revenues of $6,200,000,000 to $6,450,000,000 adjusted EBITDA of $575,000,000 to $615,000,000 At the guidance midpoints that represents 2025 revenue growth of 6% adjusted EBITDA growth of 19%. Embedded in our 2025 outlook is an points of margin expansion, driven largely by the expected annualization of new state DPU programs to begin in 2024.

Are targeting an additional 100 to 200 basis points of margin improvement over the next three to four years. That would put us solidly in our target mid teens adjusted EBITDAR margin range. [indiscernible] we begin 2025, we are encouraged by early volume trends. All signs continue to point to demand remaining durable although we continue to face some industry headwinds including ongoing subsidy pressure for hospital However, more than offsetting these headwinds are the tailwinds of underlying volume growth above historical average commercial rate increases, incremental DPP contributions and core operating initiatives that will drive margin expansion and set Arden up for strong EBITDA growth of 19% at our guidance midpoint. We certainly recognize there continues to be a level of uncertainty for the broader healthcare industry, including providers. As everyone knows, a number of potential changes are being discussed in the headlines, but we continue to believe that changes will ultimately be incremental in nature and we believe we are relatively insulated against many of these risks on several fronts. First, our 2024 exchange payer base contributed only 3.6% of total revenues in 2024, And we believe only a fraction of this volume would be at risk if the enhanced subsidies were not extended in 2026.

Second, broadly speaking, we would likely have more limited exposure to site neutrality proposals given our relatively smaller ambulatory footprint. And third, we naturally don't have exposure to 340B drug pricing if there were changes on that front. We of course continue to monitor potential regulatory changes and advocate with our elected officials to continue to support policy In the meantime, our team remains dedicated to executing day in and day out on strategic plans and financial objectives. To augment that mission, we are currently recruiting for and plan to hire a Chief Operating Officer This addition to our executive management team will further complement our existing including our M and A initiatives. We believe that augmenting the executive team with another key hire will support our efforts to help Arden maximize its potential. With that, I will now hand the call over to Alfred. Thanks, Marty, and good morning to everyone on the call with us today. As Marty indicated, Our significant growth in 2024 is a reflection of strong underlying operating performance, execution of our core margin and improvement initiatives and Medicaid DPP programs beginning in Oklahoma and New Mexico. CMS's retroactive approval of the New Mexico DP program in November for the period covering 07/01/2024, through 12/31/2024, was an important milestone for the state and is the culmination of hard work from the legislature and the healthcare community.

As a reminder, the $94,000,000 revenue and $65,000,000 EBITDA benefit Marty mentioned earlier are associated with the financial impact for the full second half of twenty twenty four. On a reported basis, we delivered financial results well above our full year guidance. 2024 revenue of $5,970,000,000 was roughly $90,000,000 above the top end of our guidance and adjusted EBITDA of $498,000,000 was nearly $60,000,000 above the top end of our range.

Even when we exclude the New Mexico DPP benefit that wasn't in our 2024 guidance, Ardent delivered strong results to finish the year Excluding the New Mexico DPP impact, full year 2024 revenue was $5,870,000,000 near the top end of our $5,800,000,000 to $5,875,000,000 guidance range. 2024 adjusted EBITDA was $433,500,000.0 or $1,000,000 above our guidance midpoint. 2024 net Ardent service revenue per slightly above the top end of our 2.6% to 3.3% guidance range. And 2024 adjusted admissions grew 4.8%. Again above the midpoint of our guidance range of 4.5% to 5%. [indiscernible] In terms of the fourth quarter of twenty twenty four, year over year growth rates are higher due to the New Mexico DBP benefit as well as the cybersecurity incident that took place in the fourth quarter of twenty twenty three. That said, on a reported basis, total revenue for the quarter was $1,600,000,000 increase of 19% compared to the fourth quarter of twenty twenty three. Adjusted EBITDA for the quarter grew 213% compared to the to $183,000,000 For the full year 2024, reported revenue increased 10% year over year, and adjusted EBITDA grew 58%. Our adjusted EBITDA margin for 2024 expanded two forty basis points from 10.1% in 2023 to 12.5%.

Advancing materially towards our long term target of mid teens adjusted EBITDA margins. In terms of revenue mix, 2024 Medicaid declined 90 basis points year over year to 10.3%. This decline largely reflects the impact of Medicaid redeterminations On the flip side, our commercial mix increased 100 basis points year over year to 43.6% driven primarily by growth in exchange volumes. As Marty mentioned earlier, our exchange revenue contribution is still a modest 3.6% of total 2024 revenue. In terms of reported volumes, represented an increase of 11.5% over the prior year. Growth in general medicine, cardiology and neurology were particularly strong. For the fourth quarter of twenty twenty four, adjusted Total surgeries increased 6.3% year over year reflecting inpatient and outpatient surgery growth of 8.75.4% respectively. NER visits in the fourth quarter grew 6.7% year over year. [indiscernible] Contract labor expense represented 3.6% of total salaries and benefits for the fourth quarter of twenty twenty four compared to 4.3% to the comparable quarter a year ago. We continue to see contract labor utilization and rates normalize across our markets as well as improvements in our nursing retention rates. Moving on to cash flow and liquidity. We ended the fourth quarter with total cash of $557,000,000 and total debt outstanding of $1,100,000,000 Our total cash and available liquidity at the end of the fourth quarter was $845,000,000 Cash provided by operating activities during compared to $67,000,000 for the fourth quarter of twenty twenty three.

Capital expenditures during the fourth quarter were $81,000,000 up from a quarterly average of $35,000,000 for the first three quarters of twenty twenty four. This step up in capital spending was largely We finished the year with $188,000,000 of CapEx spend just above the top end of our guidance range as we opportunistically took advantage of buying out some surgical robot leases. At year end, our total net leverage as calculated under our credit agreement was 1.2 times and our lease adjusted net leverage was 2.9 times down from 3.5 times at the end of the third quarter. So as we turn to 2025, we remain focused on delivering value to our patients and shareholders. While it's early in the year, we're encouraged by our volume trends and that gives us increased confidence in the durability of the demand we're seeing In yesterday's earnings release, we provided initial 2025 guidance that at the midpoint implies revenue and adjusted EBITDA growth, of 619% respectively. Additionally, the midpoint of our guidance implies 2025 EBITDAR margin expansion of 110 basis points to 13.6%. Embedded in our 2025 outlook dollars in EBITDA from DPP programs. This increase primarily reflects the expected full year impact from the New Mexico and Oklahoma DPP programs.

This is consistent with our previously communicated expectations for growth in DPP programs in 2025 over 2024 The only mechanical nuance is the $65,000,000 we were recorded in 2024 from the retroactive approval of the New Mexico DPP program was not in our 2024 guidance. So now the 2025 year over year EBITDA increase attributable to DPP programs is expected to be $75,000,000 versus the $140,000,000 that we've previously discussed. A complete list of our guidance metrics is provided in our earnings release. But some key highlights include total revenue of between $6,200,000 and $6,450,000,000 net income attributable to Ardent Health of $245,000,000 to $285,000,000 implying full year diluted EPS of between $1.73 and $2.01 Adjusted EBITDA of $575,000,000 to $615,000,000 total adjusted admissions growth of between 23% net patient service revenue per adjusted admission growth of 2.1% to 4.4%, and we expect capital expenditures of between $215,000,000 to $235,000,000 or 3.6% of revenue at the midpoint. As a reminder, this increase is consistent with our previous comment that CapEx would likely approach 4% of revenue over time.

While we aren't going to be providing specific quarterly guidance, we did want to comment on earnings seasonality. At a high level, and the first and third quarters to be our lowest. This year, the timing of CMS approval of the 2025 New Mexico alter quarterly earnings recognition New Mexico submitted a renewal application in December 2024. Given the ongoing transition to the new administration, it's possible the 2025 program won't be renewed by the end of the first quarter. In that scenario, we would not record any new Mexico DPP revenue in the first quarter and instead would have cumulative revenue recognition of 2025 program amounts in the quarter that CMS approval is received. This would not affect the annual contribution is a factor to consider in quarterly modeling. So with that, I'd like to turn the call back to Marty for a few final comments on the quarter before we open the call to questions. Thank you, Alfred. In summary, we continue to make substantial progress as we execute on our key strategic initiatives and leverage the consumer focused platform we have built to create long term shareholder value. Are pleased with our strong finish to 2024 delivering attractive financial and operating performance for the year.

We continue to advance our focus on market share growth, taking a disciplined approach to evaluating opportunities in both the ambulatory space as well as acute care hospitals, our NextCare acquisition squarely fits into this With leverage below 3x and ample cash, we will continue to assess opportunities Finally, we are encouraged by volume trends to start the year and Ardent focused on sustainable growth in 2025 and beyond. I want to close by thanking our 24,000 team members and more than 1,800 employed and affiliated providers who continue to deliver exceptional care to patients across the communities we serve. Together, we are focused on making healthcare better fulfilling our purpose of caring for our patients, our communities and one another. With that operator, please open the line for questions. Thank you. We will now begin the question We'll take our first question from Whit Mayo at Leerink Partners. [indiscernible] Hey, maybe just to follow-up, Alfred, on that last point on New Mexico, just to make sure I get this correct. So you need approval from CMS So we should do we just take the 65, divide that by four and say take that out of the first quarter and apply it to a different quarter?

Is that Is that basically the math to do? Hey, Whit, this is Alfred. Yes, you've got it generally correct. Now the $65,000,000 is the year over year increase attributable to New Mexico and of course we booked the 65 in the representing the last half of the year or so. When you think about quarterly amounts, yes, it's not wrong to think about that total quantum [indiscernible] Okay. And then my follow-up is just I mean the volume certainly stand out as being fairly robust versus what we've seen reported from the peer group. I was just hoping maybe you could unpack this just a little bit more just how broad based it was across the portfolio, any one market materially outperforming others and then you referenced in your prepared comments that the demand or volume environment continues to remain strong. Guidance this year is 2% to 3% on adjusted admissions, which feels more normal. Maybe this is just some conservatism here, but maybe just to put some of that into context. Thanks. Hey, Whit, this is Marty. I'll start and then turn it back to Alfred. But yes, to the question about volumes and durability, we continue to believe in the strength of the positions we have in our markets and our markets are continuing to grow.

This is not a one off in one market or another. See it's pretty consistent across the portfolio. And we're encouraged by again, as Alfred said, early signs of volume demand in the first part of this year as well. So nothing to call out specifically just to get continued strength and strong positions in our markets and growing markets Ardent continuing to operationalize through our transfer centers and through our internal efficiencies, how we'll be able to take more transfers into the system and service more demand [indiscernible] Yes, just tailgating on Marty's comments with, yes, as you saw in our release, year over year adjusted admissions increased for 2024 almost 5% at at 4.8%. Now clearly 2024 benefited from to midnight rule We put that year full year increase in the kind of thing of that as maybe 140, 150 basis points of that increase. So stripping that out, we were just north of 3%. Call it 3.2%, 3.3%. And as you saw in our guidance today, we've have a range of 2% to 3%. And yes, so Maybe perhaps a tad bit of conservatism in that range. And to Marty's point, we think we've all heard the kind of the strength of the respiratory season.

And yes, we feel we feel very good about continuing the same trend given the strong markets we're in. That we'll continue to see growth.

Thanks. We'll move to our next question from Ann Hynes at Mizuho Securities.

Great. Thank you. Good morning. I know at a recent conference you highlighted physician expense was a little bit more pressure than you expected. Can you just provide an update on how that is trending? Then in your prepared remarks, you talked about over the next three to four years, ex the DPP program, you have a path to 100 basis point of baseline margin improving improvement. Can you remind us what the drivers of that margin improvement is And within that, what do you expect like an annual growth rate is for this physician expense? Thanks.

Good morning, Ed. This is Marty. I'll start Ardent then I'll let Alfred take second part of your question. On the physician expenses, we did see the hospital based physician subsidies moderate from 23% to 24 And from 24% to 25%, we expect it to be somewhere in that similar range. It has come down from the peak in 2023 but it's still running slightly above inflation. From what we would have otherwise expected. We are seeing good movement with our renegotiations. We substantially renegotiated our ER and anesthesia contracts during that 03/2004 period.

We've seen some modest pressure from radiology to radiology is also a smaller portion of those total subsidies. So we're continuing to monitor that. Our operational teams are working diligently with our different vendor partners in each of our markets and some of our local providers to offset some of those headwinds. And we expect this to continue to moderate as we go through the year. Yes, Ann, this is Alfred. I'll touch on the second part of your question, which is the margin improvement initiatives. Over the next three to four years attributing to the improvement in our overall margins. We would put that into a number of different buckets. And as you can imagine, just given the profile of our E and L a healthy dose of that comes in the form of both labor initiatives as well as supply chain initiatives. And that can include a number of overhead G and A expense and continuing to focus on our service line optimization improvements from technology enhancement. So I would say it's a whole litany of efforts and initiatives that we have plans over the near end intermediate term.

Great. Thank you. We'll take our next question from Scott Fidel at Stephens. Hi, thanks. Good morning. First question, just would appreciate if you can give us an update into just how the JV pipeline and conversations are developing or sort of in flight. Here early in 2025? And then I would be curious just around how you think about the effects on the JV discussions just from the the legislative funding reform talks in Washington.

Curious whether that's something you would see as a potential accelerant to that as potential partners may be looking to another partner to help optimize performance against the backdrop of maybe some more funding pressure. Or is it just sort of providing a near term chilling effect just as partners may want to see how ultimately the I guess the legislative sausage making ends up sort of playing out in Washington?

Hey Scott, thanks for the question. This is Marty. Our JV pipeline, I say our acquisition pipeline in general, both on the outpatient and the inpatient continues to build. We're encouraged by the progress they're seeing and the conversations that we're having While we don't have anything to report right now, we are continuing to be encouraged about our growth trajectory that we've previously spoken about and see that JV partnership as an important part of that strategy as we go forward. The effects from potential changes in Washington on JV partners, I would say that there's definitely concern particularly those academic [indiscernible] I think that that will put pressure on their plans and I think that that will ultimately benefit us as we look towards new expansion opportunities. Certainly the conversations, as I said, have been robust and continuing to build, but not seeing any direct impact yet is what you alluded to. I think people are still trying to understand the magnitude of what these changes might be and there's still a lot of uncertainty out there. There's been a lot of a lot of discussion, but not a lot of details coming out of some of those.

So In summary, we continue to be optimistic about the pipeline that we have for growth think that some of these changes will ultimately provide a modest tailwind to our growth Okay. And then just my follow-up question, if if maybe you can sort of give us your projections for operating cash flow for 2025? And then then relative to, I guess, both cash flows and then CapEx guidance you provided any qualiads you'd want to give around sort of from a modeling perspective, any seasonal considerations that we should be thinking about separate from the Mexico PPP, just anything else Alfred, for seasonally from either cash flow or the timing of the CapEx set think we should be considering it when we model that? Thank you. [indiscernible] Yes. In terms of seasonal considerations, on CapEx, I wouldn't this year we had a pretty significant skew towards Q4 as you saw in our Q4 numbers. Now some of that was as I mentioned we had a real good opportunity to buy out some CapEx leases, so that skewed it even more. I think there still is a tendency for our CapEx to be a little bit back half loaded. So I wouldn't hesitate to skew it, but certainly not to the extent that we saw from a back end in 2024, but and you Ardent course seeing a step up in our CapEx spend as consistent with our expectations for ambulatory investment.

That we're making and that's embedded inside of our guidance. In terms of we haven't provided formal guidance for operating cash flow for the year. We could see that being in the upper 400,000,000 in terms of a very broad based estimate Okay. Thank you. We'll move next to Ben Hendrix at RBC Capital Markets. Great. Thank you very much. I wanted to follow-up on the professional fee and subsidy commentary. I was wondering if you could quantify how much more professional fee expense you're including in 2025 guidance versus levels you may have been contemplating like two quarters ago, late twenty twenty four timeframe? Yes. This is Alfred Ben.

I would say [indiscernible] perspective obviously and our commentary that we made at JPMorgan in January is consistent with our expectations that it will continue to be a headwind. It will continue to grow. As a percent of revenue. On a year over year basis. We think 25% that growth in '25 is actually going to look a lot like the growth in 2024. Certainly nothing like we saw in 2023 where we consumed over 100 basis points of margins from that step up, but we're seeing a sustained a sustained headwind in 2025 that will look similar to what we saw in 2024.

Great. And then just separately, appreciate all commentary about the acquisitions, the eighteen Urgent Care Clinic, Could you just maybe talk about what you're seeing in terms of the pipeline across your markets in terms of both Ardent care and ambulatory tuck ins?

Hey, Ben, it's Marty. Yes, we see continued opportunities for expansion in our markets. Again, we've had historically a lesser percentage of outpatient services, maybe relative to our peer group. And we know in our Ardent, given the growth in those markets, there's opportunities to expand both in the hospital and beyond the hospital And so Ardent Care was that early focus that we set out we went public last year and we've made good progress on those commitments. We see continued opportunities for expansion of Ardent cares, both perhaps from an M and A perspective, but also from a de novo as we continue to round out pockets of geographies where we don't have representation. But we're also going to be turning our focus this year into other ambulatory assets Continued expansion of what we set out to do and we still see good demand for the services growth across our markets. Thank you.

We'll go next to Joanna Gajuk at Bank of America. Hi, good morning. Thanks so much for taking the question. So I guess first, a couple of clarifications. So Q4 volumes, right, these metrics are essentially skewed because there was easy comp a year ago, right? There was the cyber security event. Right. That's correct, Ann. That's Marty.

Yeah.

Okay. And then because I'm sorry, go ahead.

No, you're exactly right. This is Alfred. The cybersecurity Ardent started on Thanksgiving last year and certainly had an impact through the end of the year from an overall volume perspective. So we say it was an easy comp, but clearly our volumes were impacted by the outage.

And what would you say, is there at a way to think about a full year benefit that you saw in 2024 because of that easy comp? I mean, I guess, the flip side, it's probably some headwind that you had in early Q1 'twenty four, right, because it was continuing. A little bit there. Just thinking about your volume up for 25% to say there's a $2,000,000 room that the benefit will not repeat. And I'm trying to think the two to three versus three, like is there also a reason because of this dynamic year over year 2024 Ardent maybe had an easier comp?

Yes, this is Alfred. I would say we've been pretty clear that the cyber event was largely behind us as we turned the calendar into January. So I don't think from a '24 to '25, it's really embedded in in the volumes. We have said from a to midnight rule, again from a full year basis that is maybe 140 basis points of our adjusted admin growth which again full year 2024 was 4.8%. So with without the tube and I, we think it would ballpark been in the mid-3s, call it three point three three point four. So but again, I would say, when you think about the cyber event, the 2425 comparisons are going to be really clean.

Right. And you had mentioned that Q1 trends so far where you're seeing an uplift. So is this really the the flu season of the respirator lower case is kind of higher year over year.

Yes, clearly, as Marty indicated, indicated, we feel good about how the year started from a volume end. We've all heard about the strength of the flu season. Now again, those are those certainly provide volume and [indiscernible] again it goes to our overall strategy terms of growing our ambulatory footprint, being able to see the right patient in the right setting, But, yes, so clearly from an admissions per perspective, we would expect that the appeal will have some modest impact to 25 because this does appear to be from a multiyear standpoint, a stronger not just flu, but other respiratory illnesses. But again, I would consider those to be generally much lower acuity and not driving a material financial benefit.

Okay. Thank you. And if I may last follow-up on a comment, I appreciate your comments around these potential, I guess, proposals that being be material [indiscernible] want to follow-up on that because I guess there is a branch of things, right, that being considered when we say that neutral there's other physician administered drugs, so that will be Not that material, but I guess the other end of the spectrum is kind of changing the reimbursement for some of the surgeries, right and pay them at the lower level at ASC level. So if that was to happen, like how would you think about trying to kind of quantify the impact of that type of Ardent neutral reform for your company? Thank you.

Yes, Joanna, this is Marty. Again, to your point, there's not been any clear communication on if or what changes might occur related to site neutral. There's certainly been a lot of chatter As we stated before, our exposure to the freestanding site neutral services are much more limited given our smaller footprint. It's an area we're growing into, but it's not an area that we a big exposure on today. So, as we look at that, we expect that that's impact. There's a report of 66 APCs that has been floated out there. If that were to come to pass, I think that that's a stretch to say that it would all happen. Our quantification is somewhere less than $10,000,000 impact. Great. Thank you. Our next question comes from Craig Hettenbach at Morgan Stanley. Yes. Thank you. Nice to see the New Mexico DPP come through. Can you just talk about just the visibility and durability of those programs as you see it for this year and beyond?

Yes, Craig, this is Marty. Thanks for the question. We were excited to see that. Our teams did a lot of work to help make sure that that happened and we can get additional reimbursement for caring for that population across New Mexico. It's really helpful for us and all providers across the state. Given that this program was approved, if we look back historically, these programs started back in 2016 and there's not been a program that we're aware of that once been approved, it's not been reapproved. And so we consider this in the approved category And while we understand that CMS has been sort of on a restrictive communications protocol waiting for the the confirmation of a CMS administrator. We do expect that these programs will continue to move forward. They are important not only to companies like us, but again providers all across the state. And this is really just helping to defray some of costs that have not been historically covered by Medicaid, providing for those patient populations. And so we still see these as very durable, very necessary and important Ardent the safety net.

Of states across the country and as recently as yesterday, President Trump in his first cabinet meeting again reaffirmed that he was not going after Medicare, Medicaid programs that they'd be targeting fraud and abuse. And so all of that is indications that we expect these programs to remain durable into the future.

Got it. And then just a follow-up on commentary around acuity. Outside of just kind of flu season, anything else you would call out in terms of just underlying trends you're seeing across the business from an acuity perspective? This is Marty and I'll let Alfred chime in here. But Acuity continues to be strong. Again, we think that that's largely part because of our focus around our service line optimization initiatives, capacity initiatives, transfer center initiatives is just making sure that we can care for those acute cases that have need and services while caring for lower acuity patients. A little bit more about the specifics. Yes. The only thing I would add, Craig, is clearly the two midnight rule in 2024 did have an acuity impact because you did see these lower acuity admissions move from ops. And so overall, our CMI nudged down a little bit as consequence of those two. But of course, we lap that in 2025. So yes, we would continue to expect to say acuity consistent with 2024 Ardent again going to our expectations for growing our continuing to see focus on seeing the right patient in the right setting We think overall that should have a longer term benefit on our [indiscernible] Helpful.

Thank you.

We'll go next to Matthew Gillmor at KeyBanc. Thanks for the question.

I wanted to ask about the length of stay metric. You've done a good job driving that lower in 2024. Maybe there's some influence with the two midnight dynamic that Alfred just mentioned. Marty had talked about the device you've been rolling out to collect vitals and improve nurse rounding. I was curious how that rollout has been progressing? Is it having a discernible impact on like to say at this point?

Hey, Matt, this is Marty. Thanks for that question. Yes. I think you're right from the beginning, the length of stay with the impact of the two midnight that we offered to quantify before certainly had some portion. But again, our efficiency metrics and our focus around efficiency across the platform has been additional to that. The device that you mentioned, the bio button, we have continued to see rollout. It's don't have the exact statistic in front of me in terms of the number of facilities beds that it's in right now, but we continue to see good progress both from a clinical outcomes perspective and reduction of mortality rates. For patients that have that device as well as a length of stay impact that has been additive to the other operational efficiencies that we've been focusing on. And so it's difficult to segment out how much is attributable to the device force versus other things. But collectively, it has been an impact that we expect to continue to expand throughout the system.

That's great. And then just a quick follow-up for Alfred, just on the mechanics of the accounting for the New Mexico DPP, the 25 portion. Does that need to get approved by March 31 for you to pull it into the first quarter? Or even if the approval comes say in mid April, you'd still be able to recognize that for the first quarter.

Thanks, Matt. No, I appreciate that clarification. Yes, we would expect that the accounting would follow the approval dates. So that if the approval came after the March that that would push recognition cumulatively to whatever quarter it was accrued.

Got it. Thanks very much.

Thank you. And next, we'll move to Benjamin Rossie at JPMorgan. Hey, thanks for the question. So just following up on Acuity here on the I've seen a pretty sizable delta for your 2025 net patient service revenue per adjusted admissions growth range.

Can you just walk us through puts and takes being contemplated across your pricing mix and maybe what brings you closer to the upper end or lower end here? Yes, sure. I'll start. Obviously, the range is influenced. It's mostly kind of a back end calculation based off of the range of of revenue and adjusted admits. I'll comment on our what we're seeing from a commercial rate per perspective, we continue to see renewals above what I would call historical ranges in the 3% kind of range. We've been well over 4% from our most recent renewals. And so we continue to expect and push for as consequence of the types of inflation. We've talked to Ad nauseam about the impact of professional fees on our business And so I would say we're continuing to it's not an easy payer environment as you might guess, but we've continued to be successful into getting the type of reimbursement increases that we need given the underlying cost inflation in our business That's really what I would comment on that again that range is kind of necessarily why just given dynamics of the width of the revenue range.

That makes sense. So this is a follow-up then on the ACA sign ups. I know you mentioned that exchange is about 3.6% of revenue, but just looking at the initial sign ups in like the low double digit range in a market like Texas, how are you thinking about contribution from the exchanges to your 2025 volume growth? Expectations? Yes, this is Albert.

Again, while those growth rates are impressive and I think our markets are probably slightly north of the averages overall, given a relatively small compared to our peer set, exposure to those exchange volumes, it's still a relatively small, even though it's a large increase on a small base, it's still a small number overall. So it's I would say it's not meaningful to call out an overall growth perspective. And as we think about obviously there's been a lot of speculation around HICS exposure post 2025 with the expiration of the subsidies It is still perspective that those lives will go somewhere if again assuming the I'll say the worst happens and those subsidies and nothing comes in place those subsidies. We still feel strongly that it would likely track to not maybe not a dissimilar experience to Medicaid redeterminations where those lives end up going somewhere and that it's not [indiscernible] our overall small exposure, again, I would say we're not we don't as you look at our overall growth that's still a very [indiscernible] Yes, I'll just add onto that Ben, that coverage is good and I think that that is what is going to be necessary and I think Congress weighs, how it deals with healthcare issues, the strength of the ACA even though it's a smaller percentage for us, is very necessary part of, again, the healthcare fabric.

So we continue to advocate for those programs to be there so that patients don't lose coverage across our footprint or anywhere else across the country.

And this is Al. But the last thing I would add is that the overall revenue contribution and margin contribution from those Hixlives is going to be closer to a Medicare rate than it is actually a traditional Commercial, right.

Got it. Thanks for that, clarification. Is it fair to say then that there's maybe a a 10% to 15% kind of discount then from like your Medicare traditional commercial just to bridge that ACA reimbursement dynamic I want to be sure I follow your question. I'm not sure I captured it.

Just trying to think of a discount You mentioned that the ACA exchange plans kind of come in line more with your Medicare. Just curious on how those that kind of compares to your broader commercial book?

Yes. I guess I might answer the question this way. When I think about a HICS life from a reimbursement perspective and a Medicare life and a true commercial life, I wouldn't if I was just going to give broad justice, I would say the reimbursement is if I took that quantum of difference between Medicare and commercial, it's maybe about a third of the way towards a commercial rate.

Great.

For the color there. Appreciate it.

And with that, today's conference call is concluded. Thank you for your participation.

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