Tenet Healthcare Corporation Price & Performance (THC)

Investors should take note of the cautionary statement slide included in today's presentation as well as the risk factors discussed in our most recent Form 10 ks and other filings with the Securities and Exchange Commission. And with that, I'll turn the call over to Saul. Thank you, Will, and good morning, everyone.

We delivered outstanding performance in 2024, characterized by strong same store disciplined operations and effective capital deployment.

In addition, the year was highlighted by portfolio transactions that transformed our franchise to be well positioned for long term growth with strategic flexibility and a deleveraged balance sheet. We reported 2024 net operating revenues of $20,700,000,000 and consolidated adjusted EBITDA of $4,000,000,000 which represents 13% growth over 2020 Full year adjusted EBITDA margin of 19.3% improved over 200 basis points from prior year. [indiscernible] Our fourth quarter results were above our expectations driven by continued same store revenue strength high acuity growth as well as effective cost management. Our disciplined approach has enabled us to consistently exceed our performance expectations I would note that our full year adjusted EBITDA ended the year over $600,000,000 higher than the midpoint of our initial expectations driven by strong growth and operational performance. USPI had a fantastic year in 2024, We generated $1,810,000,000 in adjusted EBITDA which represents 17% growth over 2023, adjusted EBITDA margins of 40%. Same facility revenues grew 7.8% in 2024, another year High acuity volume growth was highlighted by total joint replacements in the ASC up 19% over prior year. Importantly, customer service levels in our centers remain quite high as we earned a 96.6 overall patient experience score in 2024.

Turning to our Hospital segment, despite the sale of 14 hospital 2024. Which represents 9% growth over prior year. Same store hospital admissions were up 4.7% as we continue to open up capacity to respond to a strong utilization environment. Acuity and payer mix were strong throughout 2024 and drove a 4.6% increase in same store revenue per adjusted admission over prior year. Was an important year for Tenet as we transformed our portfolio of businesses through the multiple through multiple high multiple sales of 14 hospital and related operations generating $5,000,000 in gross proceeds and enabling significant balance sheet deleveraging. In addition, we added nearly 70 ambulatory surgical centers to the Port M and A and de novo development. And finally, over the past two years, we have returned capital to shareholders via share repurchase, retiring approximately 14% of our outstanding shares for $1,120,000,000 since our repurchase program began the fourth quarter of twenty twenty two. [indiscernible] Going forward, we plan to be active repurchases repurchasers of our shares particularly at our current valuation multiples. These actions have resulted in a portfolio of businesses that is more predictable and able to operate in a variety of environments with better margins and ample free cash flow for the benefit of shareholders.

In summary, we're very pleased with our team's performance in 2024 and we believe that we will carry this momentum into the New Year. Turning to 2025 guidance. We are projecting full year 2025 adjusted EBITDA of $3,975,000,000 which is an attractive 7% growth rate at the midpoint on a normalized basis. Anticipate adjusted EBITDA growth at USPI of approximately 8.5% at the midpoint of our guidance for '20 fueled by ongoing strength in demand and acuity, continuing effective operational execution and additional sites of care joining the portfolio. Intend to invest approximately $250,000,000 each year towards M and A in the ambulatory space and the pipeline of opportunities remain strong. We anticipate adding 10 to 12 de novo centers in 2025. Our ability to consistently scale our platform to create additional low cost sites of care for patients and physicians continues to pay dividends as it improves our overall growth profitability, capital efficiency and resilience in this regulatory environment. Turning to our Hospital segment, we are expecting adjusted EBITDA growth of approximately 5.7% on a normalized basis at the midpoint for 2025 This projected growth is expected to be driven by 2% to 3% adjusted admissions growth and the strong operating discipline that our team has now demonstrated for many years. [indiscernible] The Hospital segment's performance will be enhanced by strategic capital deployment, expanded service lines and further contributions from the new Westover Hills facility which opened in the third quarter of twenty twenty four.

Additionally, as we have noted, we have acquirers of hospitals we've sold and this should contribute to growth in 2025. Finally, we acknowledge that there is currently a great deal of focus on the impact of potential regulatory changes in our space. We have demonstrated an ability to perform well in a variety of operating environments and believe we are differentiated from our peer set as we navigate potential changes which insulates that important part of our business from potential changes in site neutrality rules. In summary, we had an outstanding year in 2024 and believe that we are in a great position for another strong year in 2025. Our guidance reflects the opportunities before us and the momentum that we carry into the New Year. Our established management team stands ready to execute our focused strategy and deliver value for patients, physician partners and in turn shareholders. And with that, Sun will now provide a more detailed review of our financial results. [indiscernible] Thank you, Sam, and good morning, everyone. We are very pleased with the strong finish to the year.

In the fourth quarter, we generated total net operating revenues of $5,100,000,000 and consolidated adjusted EBITDA of $1,048,000,000 which represents an adjusted EBITDA margin of 20.7% up almost 200 basis points from fourth quarter of twenty three. For full year 2024, we generated $20,700,000,000 of of total net operating revenues, and consolidated adjusted EBITDA of $3,995,000,000 These results were driven by strong same store revenue growth continued high patient acuity favorable payer mix, and effective cost controls. I would now like to highlight some key items for each of our segments beginning with USPI, which again delivered strong operating results. In the fourth quarter, USPI's adjusted EBITDA grew 14% over last year, adjusted EBITDA margin at 42.1%. USPI delivered an 8.6% increase in same facility system wide revenues driven by high acuity levels favorable payer mix.

Same facility system wide surgical case volume grew slightly over last year.

And turning to our Hospital segment, Fourth quarter adjusted EBITDA was $518,000,000 with margins up 90 basis points over last year.

At 13.6% normalized for the divest hospitals, adjusted EBITDA grew 13% over fourth quarter of Tenet three. Same hospital inpatient admissions increased 5% and revenue per adjusted admission grew 0.6%. Our consolidated salary, wages and benefits in fourth quarter of twenty twenty four was 41.3% of net revenues. And our consolidated contract labor expense was 2.1% SWV both substantially lower than the 43% and the 2.8% respectively that we reported in the fourth quarter of Tenet twenty three. Next, we will discuss our cash flow, balance sheet and capital structure. Our cash flow performance was very strong in 2024 with $1,100,000,000 of free cash flow for the year.

This includes the payment of $855,000,000 in income taxes related to our completed divestitures.

Excluding these tax payments, this represents nearly $2,000,000,000 of free cash flow for the year. Or $1,300,000,000 of free cash flow after distributions to non controlling interests or NCI. For full year 2024, we repurchased 5,600,000.0 shares of our stock for $672,000,000 We finished the year with over $3,000,000,000 of cash on hand with no borrowings outstanding under our $1,500,000,000 line of credit facility.

Our year end leverage ratio was 2.5x EBITDA or 3.2 times EBITDA less NCI.

A substantial improvement over the past year. Reflecting the proceeds that we received from our hospital divestitures as well as our outstanding operational performance. We are very pleased with our ongoing cash flow generation and have a commitment to a deleveraged balance sheet. We believe we have significant financial flexibility to support our capital allocation priorities and drive shareholder value. Let me now turn to our outlook for 2025. We expect consolidated net operating revenue in the range of $20,600,000,000 to $21,000,000,000 Our projected consolidated adjusted EBITDA is in the range of 3.975 to 4.175 As a reminder, there are two normalizing items that I would call out. When comparing our '25 adjusted EBITDA to the prior year.

First, we reported $114,000,000 of adjusted EBITDA from facilities that we divested in 2024 will not recur. Additionally, we reported $74,000,000 of out of period supplemental Medicaid payments Michigan and Texas in 2024. After normalizing for these items, our 25% adjusted EBITDA is expected to grow 7% at the midpoint of our range. Our 25% outlook assumes continued growth in same store volumes and effective pricing as well as strong operational efficiencies and disciplined cost controls. Additionally, we anticipate further contributions from recent investments and partnerships in the hospital segment. As well as from M and A and de novo center openings at USPI. In addition, we are also assuming the following: same hospital admissions growth of 2% to 3%, and adjusted admissions growth of 2% to 3%. And for USPI, same facility revenue growth of 3% to 6%. On a normalized basis, we expect adjusted EBITDA grow 8.5% at USPI and 5.7% for our Hospital segment, at the respective midpoints of our guidance ranges.

Our outlook also assumes $35,000,000 of net revenues from the Tennessee supplemental Medicaid programs.

About one third of this increase is related to the second half of Tenet four, and is expected to be recorded in the first quarter this year. Finally, we would expect first quarter twenty twenty consolidated adjusted EBITDA to be in the range of 24% to 25% of our full year consolidated EBITDA We anticipate that USPI's EBITDA in the first quarter this year will be 21% to 22% of our full year USPI EBITDA. At the midpoint. Turning to our cash flows for '25. We expect cash flow from operations in the range of $2,500,000,000 to $2,850,000,000 Capital expenditures in the range of $700,000,000 resulting in free cash flows in the range of $1,800,000,000 to $2,050,000,000 In addition, we're also assuming distributions to NCI in the range of $750,000,000 to $800,000,000 which will result in free cash flow after NCI in the range of $1,050,000,000 to $1,250,000,000 And finally, as a reminder, capital deployment priorities have not changed. First, we will continue to prioritize capital investments to grow USPI, through M and A. Second, we expect to continue to invest in key hospital growth opportunities, including our focus on higher acuity service offerings. Third, we will evaluate opportunities to retire and or refinance debt And finally, we'll have a balanced approach to share repurchases.

Depending on market conditions and other investment opportunities. Given our attractive free cash flow profile, and current valuations, we plan to be active repurchasers of shares 2025. In conclusion, we had an outstanding year in 2024 with effective operational execution, robust growth and a transformed portfolio of businesses. We're confident in our ability to deliver on our outlook for 2025 and continue to drive value for patients, physician partners and shareholders.

And with that, we're ready to begin our Q and A. Operator?

Thank you. At this time, we'll be conducting a question and answer session. We ask that you please limit to one question. Our first question comes from Peter Chickering with Deutsche Bank. Please proceed with your question.

Good morning, guys. Thanks for taking my question. So looking at attendance over the last few years, the biggest change has been the cash flows and you're deleveraging. Your cash flow guidance for this year is up 90% year over year with nearly billion dollars more cash flow from operations. So looking at your cash flow guidance for this year after NCI, it's about point $15,000,000,000 at the midpoint. If we pull out $250,000,000 for M and A, it's about $900,000,000 left to [indiscernible] To leverage us for 3.2 times EBITDA less NCI you refresh us on what your ideal target leverage ratios are? And should we be modeling the rest of that going share repo at this point?

Hey, Peter, it's Tom. First of all, I appreciate reiterating the improvements that we've made in generating free cash flow from this business from operations It's obviously been a very important part of our our goal over the last few years and getting to this point probably earlier than we thought We're very comfortable with the leverage that we operate at today. And importantly, it gives us we look at it and say it gives us significant strategic ability with respect to the business, both in terms of activity that we may pursue in growing and scaling USPI. As I noted in my comments, but also also from the perspective, especially as I said, if these valuation multiples In terms of share repurchase and both Sun and I noted that we would plan to be active repurchases of our shares at these multiple multiples makes complete sense. We don't have debt coming due for a couple of years. Right? I mean, so we're not in any situation of urgency there regardless. And I think the return on share repurchase at this point would be higher anyway.

So our thinking is relatively clear about that. The coming years. Obviously, we need to continue executing operationally with the track record that we've built to generate that free cash flow. But as we've talked about in the last couple of years, we've really hardwired our approach there The last thing I would point out in in addition to what I said about USPI in my comments We don't USPI does not have a tremendous amount of Medicaid exposure. So So when you think about utilization of our cash flows and regulatory risks that may be out there. I mean, the reality is half our EBITDA is generated in a segment that isn't really facing risk from any scenario out there related to Medicaid programs and that's very helpful. It's very different than it might have looked five or six years ago. So we feel confident about the valuation opportunities for the company. Our next question comes from Jamie Purcell with Goldman Sachs.

Please proceed with your question. Can you maybe spend a minute on just the the volume environment that you're seeing today? Obviously, 2023 and 2024 were pretty strong years. Some of that just recovery and normalization post the pandemic.

Where do you think we're at from a volume perspective?

Today? And how do you expect volumes to progress throughout the course of the year? Yes. Thanks, Jamie.

I mean, the simple statement I would make right now is that we've anticipated the volume environment continuing to be strong coming into 2025. Mean that's the simplest summary statement I would make. We don't there aren't obvious trends from December 31 to January 1 that appear to have changed I mean the coverage environment looks good, the employment environment looks good, demographics both in terms of areas where at least our portfolio is now positioned relative to where it was has attractive demographics, and as we've noted, we've had opportunity to expand capacity and take on that capacity without excessive cost to do so and we're doing it in a deliberate deliberate way. So we I mean our guidance reflects that we feel pretty good about Going into twenty twenty, 'twenty five, Our next question comes from Brian Candlewick Jefferies. Hey, good morning guys and congrats on the quarter. Maybe Sam, as I think about your comments on Medicaid and USPI, just curious how you're thinking about the risk overall for the company from all the political headlines that are out there and what the republics are trying to do with changes to healthcare policy and what you're doing to prepare for that just for that potential change, whether it's Medicaid or health insurance exchanges across both business lines?

Thanks.

Yes. Thanks, Brian. A few things. So I mean, first of all, the fundamental underpinnings of success in an environment with any kind of uncertainty in our view is operating discipline in what we do, right? [indiscernible] the other important underpinning is having a clear understanding of the economics of our business internally meaning we understand clearly our service lines our markets, etcetera, that may have greater dependency or less dependency upon certain types of supplemental payments, where, for example, the strength in the exchanges has contributed to earnings, etcetera. So the combination of the operating discipline and the insights about the business probably give us an opportunity to manage and pivot as needed depending on what happens. You're right, the segments are different. I mean, we've taken the opportunity over the past few years to create resiliency in USPI by making sure that the ambulatory surgery centers as a part of USPI are on freestanding rates. The Medicaid exposure is de minimis in that business and that's very helpful from that perspective And the exchange business there has had less impact than it's had on the acute care segment in terms of the exchange growth. From that perspective. So from a USPI perspective, look, this is all about an important tailwind of moving things into a lower cost setting in an expensive portion of the health care industry, which is surgical care, right?

And doing so in a way where we're constantly increasing the acuity of the work at USPI because it creates more value for the purchaser. On the acute care hospital side, I think it's important to continue to search for efficiencies that allow us to generate margins We always talk about the concept of Medicare profitability, right? Can you generate in order to have a metric out there for efficiency goals that you would you would create because it's important to be able to operate in that type of environment. Specifically on the acute care side, The number one adaptive action today is helping the regulators understand the importance that these programs provide for basic access for people that wouldn't otherwise have access to care. [indiscernible] if that shapes or is a factor in shaping policy, I think that what comes out of that policy will likely be manageable for us. And and something that we can get behind. I think there's a very strong case to be made that many of these things are really critical to providing access And it happens to be that that access is also being provided in states with voters that really matter to this administration.

That's an important supporting factor as well.

Our next question comes from Andrew Mak with Barclays. Please proceed with your question.

Hi, good morning. When I look at the ASC case mix, from 23% to 24%, it doesn't look like there are significant mix changes. We actually actually see MSK down one percentage point and ophthalmology up one percentage point.

You're increasing acuity significantly to the point where you're seeing high single digit same store revenue growth without meaningful case growth. So can you speak to the types of cases driving acuity higher because it's not obvious from the case mix Yes, no problem. I mean just to clarify, the orthopedics line item has a lot of things in there That's why we call out the highest security work in joint cases. For example, which is where where you have the hips, knees, obviously, the shoulder expansion That's where the acuity is actually growing. I mean, remember, when you look at certain low acuity procedures that we may do in ASCs, the revenue per case is an eighth or a ninth of a single joint case, total joint case from that perspective. So mean we're doing exactly what we wanted with the business, which is we're growing the acuity, we're growing the net revenue per case, We are reducing exposure to high volume, low revenue cases in some cases things that could also be done in offices [indiscernible] that further strengthen the resiliency and value of what USPI is building. So that orthopedics line item has a lot things in there from high acuity to low acuity cases.

And it's the reason we call out the really high acuity work This is a fundamental driver of the net revenue per case strength, which you're seeing.

Great. Thanks for the color.

Sure.

Our next question comes from Justin Lake with Wolfe Research. Please proceed with your question.

Thanks. Good morning. A couple of things, just numbers wise. Maybe you could tell us you've mentioned Tennessee as a tailwind in that $35,000,000 You mentioned, for instance, Michigan is not going to you're going to have a little bit of a one time headwind there. [indiscernible] when you think about ex those issues kind of core DPP dollars year over year, Can you tell us what's assumed in the guidance? And then same for exchanges like what kind of exchange growth do you kind of expect in your markets, exchange volume growth, within that guidance? Thanks. [indiscernible] Sun and thanks for the question. On your question about supplemental payments, yes, I think you called out the kind of the one timers that we we've referenced. The other point fiscal 'twenty four, Tenet still had a little bit of value from hospitals that were then that divested during the course of the year, but that's mostly in Q1. So there are a couple of those moving factors. But in fiscal twenty twenty four, we generated about $1,160,000,000 of Medicaid supplemental payments Going into '25, our guidance assumes You mentioned the October Tenet, but excluding that we're pretty consistent year over year.

On your question about exchange, As we've said multiple times, total emissions and revenues from exchange population was a strong growth driver in 2024.

We expect that to continue per Sam's earlier comments around the overall volume environment. The enrollment, the renewal cycle seems to have been positive. We'll see how much of that turns into actual [indiscernible] But we certainly won't see the the 40%, 50% growth that we saw in 2024, but we still continue to see a strong environment. Just as an example, we're our strategy long term strategy has always to be in broad networks from a contracting standpoint as an example. So we see good things for 2025.

Our next question comes from Benjamin Rossie with JPMorgan Chase. Please proceed with your question.

Hey, good morning. Thanks for the question here. So just across supplies, we're some pressure here as a percentage of revenue with that category increase in about 100 bps year over year to eighteen point three How would you characterize your current supply dynamics exiting the quarter? There anything discrete occurring within there? Is this largely a byproduct of your push into higher acuity? Kind of curious where you're seeing that number settling out in the steady state 2025?

Thanks.

Yes. Hey, Ben. Yes, I think it's what you said on the latter piece. It is just kind of parcel with our acuity strategy. So the supplies will go up as a percentage a little bit in Q4. But over the year, we've been pretty well balanced and we expect it to be, again, balanced in '25.

Our next question comes from Joanna Gajuk with Bank of America. Please proceed with your question. Hi, good morning. Thanks so much for taking the question. So on the guidance element, unbilled dairy same store revenue 3% to six normalized growth, right? Because clearly you grew very nicely in 2024, almost percent. So is it just conservatism? Could you maybe also break down volumes versus pricing that's included in that range? Yes.

Hey, it's Tom.

Look, a couple of things there.

First of all, Long term, as we've learned with USPI and I think we've shared this data and Same store growth rates of around 4% to 6% is what we guide to. Now history suggests over that ten year period, we've performed at the upper end of that range 6% That has looked better strengthened over the last five, six years actually over that average period, okay? So you point out this year almost or this year, past year 247.8%. The prior year was 9.2%. Growth rate. So we're running very hot from that perspective in terms of long term averages with respect to USPI. So our guide just comes brings us right back to what our long term growth rate is In terms of the year to year, as you've seen, it can be lumpy, right? '23, huge volume growth, '24, more growth in acuity and intensity and part of what we're signaling for '25 is it's definitely our plan to continue this shift to higher acuity procedures. I started to point out some of the factors driving that in terms of the revenue intensity of some of these how efficiently we're able to do them in our operating rooms now and generate generate margin, how we are scaling those programs into more centers We now have robots in almost 150 of our programs around the country, This is the direction in which we're taking the organization And so yes, the guidance reflects kind of our long term average, but we've obviously been running quite a bit above above that Our next question comes from A. J. Rice with UBS.

Please proceed with your question.

Hi, everybody. Thought I would ask maybe on where you're at with managed care contracting.

I know we've been in a period where you've been getting a little bit toward the high end of historical rate updates to pay for some of the labor challenges in the last few years is 25 a year in which you'll still see that type of dynamic maybe where you're at in terms of signing up contracts? And then also on the managed care side, any update on thoughts about denial activity, prior auth other term changes that you're dealing with?

Yes, why don't we take those in reverse? I mean, I would say that the environment is no different than it has been. I mean, there's a constant back and forth of administrative costs that goes into that probably is unnecessary, but obviously both sides have a point of view on that. What I would say more importantly than anything else from our perspective [indiscernible] in driving initial disputes to a very, very attractive low rate of denials is critical. And our skill set in doing that in both working collaboratively with the payers and adversely where needed on the basis of solid documentation appropriate coding compliant coding and efficient revenue cycle operations has made a big difference. We're seeing a gap in terms of lower denial rates than the industry from what we are seeing with respect to initial dispute rates. And that's good because that means we're doing things right in generating the appropriate cash flow from the work we're doing. Sun, maybe you want to comment [indiscernible] A. J, for your first part of the question, as we've said historically, we are continuing to see commercial rates increases in the 3% to 5% range and some of the contracts have been at or slightly above the high end of that range.

As respect to the inflationary pressures that you've mentioned, so I think the overall sales margin there is pretty consistent. And then in terms of contract Going to '25, we're over 90% contracted for '25 and probably about over 50% contracted for '26 as well. So we have great visibility into 2025 Tenet beyond. Thanks for your question.

Our next question comes from our next question comes from Stephen Baxter with Wells Fargo. Please proceed with your question. Hi, thanks. Wanted to come back to the same store hospital volume guidance for 2025. I appreciate you're still expecting exchange growth side of that number to some degree. But also love to hear any quantification you can offer about how much hospital capacity you'll have online in 2025 compared to 2020 trying to break out that 2% to 3% and maybe think about maybe what's the market level growth inside of that compared to how much of it's coming from capacity?

Yes. Hey, Stephen, it's obviously both. I mean, the majority of that is the market level demand that we're seeing versus the selective markets in which there's still capacity that we're bringing online, but it is a contributor, which is why I called it out before we haven't quantified what that looks like between the two numbers, but it is It is both and the majority of it is is market based demand across the board. Some of this is also related to the service line choices we make, of course, which have higher growth rates. The things The things that we're doing that are taking care of people with multiple chronic illnesses that continue to grow in prevalence are are continuing to create more demand than perhaps certain types of lower acuity work, which may be coming out of hospitals in our environment. And so that's that's really how we think about it. In terms of the growth rates. Yes. Look, it's been a it's been a very busy year in the acute care environment And as I said, I think the most important thing we're taking into the year from a mindset perspective is we're not seeing changes in the demand patterns.

That it was a comment To Jamie's question earlier, we're not seeing changes in the demand pattern right now. And so I mean, I'm not going to go forecasting what we may see in the later part of the year, but we're not seeing that right now.

Our next question comes from Michael Haw with Baird.

Please proceed with your question. Hi, thank you. Just to put clarification first in the my real one and apologies if I missed it, but your USPI at 3% to 6%, Rev growth guide. What's the volume versus pricing split on that? And then my real question I'm sorry to add one more question on policy. And I understand USPI has minimal Medicaid exposure, but for your hospital and maybe taking a different approach, just given all the news flow NIH cuts, Doge's potential focus on Medicaid, administrative costs. If Doge were to implement those cuts, It might not be overly impactful.

But still perhaps a couple percent on overall Medicaid spend. So I'm curious to hear your view if that were to happen how do you think states might react your view on the likelihood that states might potentially flow that Medicaid cut down to provider rates and impact Tenet and hospitals more broadly? Thank you. [indiscernible] A couple of different things. So let's just start with the business side of it With respect to USPI, as I indicated, there's no there's no long term deviation from our approach of thinking about half and half roughly managed care and volume at USPI. But because it's lumpy and it's proven to be lumpy, We're not guiding specifically for the year with respect to that. And you can understand that. I mean, we're successfully now two years in a row executing our strategy of of increasing lower volume, high acuity cases. And in fact, as you can tell from our quarterly beats, consistently, we're exceeding what we expect from the standpoint of what we can do in same store revenue growth that environment And so we're pleased by that that we can do that. We obviously had a little bit of fits and starts around that a few years ago.

In terms of how we were executing it. But we got it right and it's working. And I'm I'm really pleased with that. So the long term algorithm is the same, but from a short term standpoint, we're giving you the revenue guidance with obviously the track record of it being stronger. I don't on the policy side, I think to be clear, like we don't have Even in our academic medical center, enterprises and affiliations, we We don't have significant NIH or NSF indirect grant cost exposure in our business. So in particular, as you can imagine, when we saw that we thought about that in our environment and where we had RO1 grants and other things within our environment, but we don't have that significantly in our environment. I think the broader question of of Medicaid policy and other things is an important one. But look, the focus that is articulated and you can't tell what's going to happen, but the focus that's articulated on reducing fraud and abuse, including in some of the public comments made yesterday all the way in the In the Oval Office, I think one thing that people may find is that Medicaid redeterminations over the last couple of years have probably done a lot to reduce the number of people eligible or not eligible who happen to be on Medicaid And so I'm again, no way to predict for sure but I'm somewhat comforted by the fact that some of that work has already been done through this redetermination process.

So So we'll see where this goes and what remains to be seen. Finally, as to speculation speculating on what the state's responses may be, I think the states are going to be important allies across the board in advocating for the dollars that come through these Medicaid partnerships with the federal government because again, I go back to this is the only way to create access for the people that need it that are on Medicaid. This is not some program that's generating incredible windfalls for health systems on that basis. The unit reimbursement is still below the cost of that care [indiscernible] And so I think that that's going to be an important balancing factor. The states will play an important role in this.

Our next question comes from Ann Hynes with Mizuho.

Please proceed with your question.

Hi, good morning. So I know there's some big surgery center assets out there in the market. Can you remind us given your delevered balance sheet what your appetite is versus larger scale M and A in the Surgery Center business?

Hey, Ann, it's Sam. Obviously, I'm not going any kind of M and A opportunities. We're very aware of everything that's available in the market. We've proven our ability over the last few years to deploy M and A capital both on a single asset basis and large multi center asset acquisitions. I would tell you that the first year post our acquisition early last year, of the portfolio that we took on went better than we thought it would. So that's that's good news.

And as I said early on in my comments, our balance to approach things. But look, we're disciplined We believe in growth businesses. We believe in areas in which we can add value. And we have a lot of flexibility given our our cash flow generation and valuation multiple, to deploy cash for the benefit of shareholders in multiple different avenues. [indiscernible] Our next question comes from Whit Mayo with Laurent Partners.

Please proceed with your question.

Hey, good morning. Just to stick on USPI for a second. Are there any new health system partners that we may not be aware of in the last year? I know you've been selective and disciplined with the financial strength of the partners that you want to work with but I'm just not sure I've had an update or heard an update on anything new or any expanded relationships with any health systems in some time? And maybe just a broader comment on the de novo activity, the 10 Tenet 12 this year, any of those with new partners or those all existing partners? Thanks.

Yes. Hey, Wade, it's Sam. Now we haven't provided any updates on on health system partners and other things. And remember, I mean, our platform is such that we work just as effectively with partners as we do without partners of our ability to generate contract contract synergies, managed care supply chain, everything, right, in our management capacity for these assets. So we're growing the portfolio in both with both vectors. And I don't think that's going to change. I mean, I think The expansion of de novo assets can occur in many different ways. Some are in existing markets, some are in new markets, some are with MSOs that are expanding their physician side footprint and as I've said in the past, have realized that there isn't a better operator of ASCs to generate margin from those investments for those doctors than USPI So that's that's another vector of growth that that is helping to create de novo activities It's a multipronged growth strategy and I don't think that's really going to change looking forward.

Our next question comes from John Ransom with Raymond James. Please proceed with your question.

Hey, good morning. Sam, I predict you'll hate this question, but bear with me.

So we've heard from a few folks that the fourth quarter seasonal uptick is not quite what it used to be because just the fact that deductibles have gotten so high, particularly in commercial plans Do you think there's any evidence of that John, are you referring just care delivery overall or USPI specifically and delivery?

I meant I meant electives.

So electives either in the hospital or in the USPI.

Yes, elective work. Yes. Yes.

Well, it's I mean, again, I'm not sure that I'm going to be able to give you a statistically significant answer, but I would say that the seasonality in Q4 and especially as that ramps into Q1 on elective surgery it has tempered a bit. I mean, Q4 is still a more productive quarter. Our asset utilization in our USPI segment does go up still in Q4, but it has it has tempered a bit [indiscernible] And how much of it is the deductibles versus somewhat the impact of if you look at our Q4, the impact of just some of these weather events were relevant so how much of it was a seasonality shift versus some of the weather events that we I don't know that we've really calculated that. But I mean, you're picking up on something that we've sort of said, intuitively, it feels a little bit different but the general pattern hasn't changed.

And so just my follow-up and thanks for that answer.

If we look at 2023 and 2024 utilization was up for 'twenty three, I'd say electives and 'twenty four, there was a bunch of other stuff going on like tube midnight rule and cancer cases and what have you. Do you think, again, probably you can't answer this question, but it seems to us like twenty five percent Tenet kind of back to more normalized year where maybe we've cleared out all the COVID backlog and we're kind of clear all of these kind of wonky events in 2023 and 2024. Is that kind of your and is that what's implied in your guidance? Is that kind of where we are?

I mean, that is kind of I mean, at some point, we have to get back an environment where we're not explaining everything either on the basis of COVID or post COVID or whatever the case may be. No one ever gets that entirely right but I do think that that is a little bit of what the guidance implies. And as I said, I think that's that's a fair way to plan for the year. And yet at the same time, I don't see shifts necessarily in the strength the strong demand environment that we saw in 2024 yet in particular. So We'll see how that plays out.

Thank you.

Thanks. Our next question comes from Josh Raskin with Nephron Research.

Please proceed with your question. Thanks. I'm going to stick on the USBI topic. So can you speak maybe to the broader competitive landscape for ASG transactions? Are you seeing more competition and if you could differentiate between larger sets of assets or even one offs or even competitors develop your prepared remarks, Sam, you mentioned the de novo growth. Is that indicative of more what we'll call sort of organic center expansions as opposed to acquired centers?

Well, let me go in reverse Look, we think de novo development activity is really critical and we've been we've been focused on that and scaling that up. I mean, again, part of our thinking here, Josh, is that consistent with our move into more high acuity ambulatory surgical work, De Novos also represent a significant value shift in mark right, because usually what you're doing is you're building from the ground up, you're moving things into a lower cost setting, It's value for the consumers and payers in the markets to be focused on de novo's in addition to everything else that we may be doing to grow the the portfolio and expand the high acuity services, So that it's part of our value strategy there. Maybe that's why you're seeing more of it from the de novo side. In terms of the competitive landscape, no, I don't think the competitive landscape has changed. I mean, mean, the easiest way to assess the competitive landscape is to just count the center counts across different organizations and some are scaling better than others. And that probably more than anything reflects competitive the output of whatever competitive intensity exists. We've been pretty pleased with our ability to scale win competitive situations and processes where we want them and maintain high quality, high profit margin centers. [indiscernible] we always assess that pipeline every year.

The pipeline still looks good for doing that.

That's helpful. Is it fair to assume that the de novo long term returns on capital are higher?

Yes, of course. Yes, because again, it's not like building an acute care facility, right? The building costs are low. A shorter timeframe once the partnership is syndicated. There's work upfront in syndicating the partnership that takes time, but that's not a capital intensive activity. Look, I think it's a start of this, Pito pointed out one of the big changes in the organization around the generation of free cash flow We also focus on measuring and following our overall return on invested capital within the organization. And obviously, the more we shift into this ambulatory segment, the more that gets better. And obviously, the more we do de novos, we see that that gets better in terms of what we're doing in the business when we're deploying our cash. So yes, you're absolutely picking up on what we're doing for the right reasons.

Thanks.

Our next question comes from Matthew Gillmor with KeyBanc Capital Markets. Please Hey, thanks. I wanted to follow-up on the cost management and efficiency comments. The company has clearly made a lot of progress the last few years and you noted the SWB and contract labor metrics. As you look ahead, are there any areas of particular focus that are going to continue to drive efficiency in 2025 and beyond that you'd highlight for us? Sure. I mean, think that the cost management agenda doesn't change in terms of managing labor, managing supplies, managing purchase services, active vendor consolidation, activities, scaling our service lines in which we've got a cost structure that we're comfortable with. Obviously, just that scale creates opportunity. I've said the Acute Care segment, I've said all along, we're really pleased with the improvements that we've made in so many of the metrics from the standpoint of cost labor overhead, supplies, purchase services, relative to our peer set in the industry, obviously, we always continue to note that an area that we can improve is our asset utilization And that's obviously in comparison to what we look at as kind of the gold standard out there. So that's that's really an area that we're continuing to work on as we expand capacity and build volumes into some of the facilities that we took capacity offline during the pandemic from an efficiency standpoint Our global business center has contributed significantly to our cost savings.

If you think about the last four, five years, the journey we've been on of course, there's obvious unit cost savings that you see on an immediate basis, but there's a lot of cash flow that goes into actually restructuring and and building and scaling that enterprise what might have started with kind of commodity work in certain areas of finance or accounts receivable, has expanded to ten, twelve different service lines that we are now running effectively in the global business center clinical areas, clinical analytics, physician credentialing, a variety of things. And that's an important part of our efficiency agenda as we look forward as well. And it's now that it's obviously well past breakeven cash flow those savings materially contribute to what we're doing.

Got it. Very helpful. Thank you.

Our next question is from Ben Hendrix with RBC Capital Markets. Please proceed with your question.

Hi. This is Mike Marione on for Ben.

Thanks for taking my question. So ASC total joint procedures grew nicely in twenty twenty four. I wanted to hear your expectations for growth in 2025 and beyond.

And then cardiology procedures have been the latest slated to drive material growth in ASCs. Can you discuss any early progress there and when do you see these procedures really accelerating?

Yes. Hey, it's Sam. We obviously we anticipate continuing to focus on our orthopedics line of business going forward. We're not going to guide service line level volumes from that perspective. But we still think obviously there's a tailwind in ambulatory surgical growth from an orthopedic standpoint, And that's both the stuff we're doing today and expansion of the procedure set that could be done safely in an ASC. Same with cardiac. I mean, as I've said all along, the opportunity in a wide variety of cardiovascular procedures is there. I've always been clear that I think that that opportunity will proceed more slowly than people anticipate. Because of important patient safety considerations. And payer mix considerations and also the CapEx required to build a cardiac center in very different than building other types of ASCs given the equipment that you have to have in there. So the upfront investment for the physician partners and other things is much higher with potentially lower margin assets. And so economic reasons and patient safety reasons, I think this market will evolve, but I think it will evolve slower than people like to think. And we'll obviously be participants in in that as we are today.

But we're also we're not going to try to rush it and sacrifice patient safety and quality in that regard. That's helpful. Thank you. This concludes today's conference. You may disconnect your lines at this time and we thank you for your participation.