HCA Healthcare Inc (HCA) — Q2 2020 Earnings Call Transcript

Thank you, Ian. And good morning and welcome to everyone on today's call and our webcast. With me this morning is our CEO, Sam Hazen, and CFO, Bill Rutherford, as well Dr. Jon Perlin, our Chief Medical Officer. Sam and Bill will provide comments on the company's second quarter results, and then we'll open up for questions. Before I turn the call over to Sam, let me remind everyone that should today's call contain any forward-looking statements that are based on management's current expectations, numerous risks, uncertainties, and other factors may cause actual results to differ materially from those that might be expressed today. More information on forward-looking statements and these factors are listed in today's press release and our various SEC filings. On this morning's call, we may reference measures such as adjusted EBITDA and net income attributable to HCA Healthcare, Inc., excluding losses or gains on sales of facilities, which are non-GAAP financial measures. A table providing supplemental information on adjusted EBITDA and reconciling net income attributable to HCA Healthcare, Inc. to adjusted EBITDA is included in today's second quarter earnings release. This morning's call is being recorded and a replay of the call will be available later today. I will now turn the call over to Sam.

Good morning and thank you for joining today’s call. The second quarter was a remarkable 91 days for the company, possibly the most significant period I've experienced in my 37 years here. It began with a high level of uncertainty and unease as the pandemic unfolded, but the middle part showcased numerous instances of our team stepping up to support each other and our patients, all while reinforcing our culture of care. The quarter concluded with our teams demonstrating their ability to manage relationships with employees, respond to physician needs, adapt operationally, and build clinical capabilities that not only enhance our response to ongoing pandemic challenges but also position us to improve our services and deliver more value in the future. I have never been prouder to work with this company than I am now, and as a shareholder, I hope you are equally proud to be associated with HCA Healthcare. From the outset, we approached the pandemic with two clear objectives: to protect our people by ensuring their safety and employment and to safeguard the company’s financial health so we can continue serving our communities. These objectives remain guiding principles today, enabling us to provide the care patients deserve. So far, we have achieved these foundational goals thanks to the dedication and hard work of our 280,000 colleagues and 45,000 physicians. I want to express my gratitude for their unwavering commitment and sacrifices during this global health crisis. Additionally, careful planning, effective execution, appropriate resource allocation, and strong leadership contributed to numerous positive outcomes. We also collaborated closely with our partners, health plans, lab companies, suppliers, post-acute providers, and more, and I want to acknowledge their contributions. Every part of our organization has come together to do what is right. In these uncertain times, our people have continued to show up and push forward, and we remain committed to this journey. In pursuit of our first objective, we introduced various pandemic pay programs to support our colleagues, including one that ensured income for those affected by stay-at-home orders and reduced patient volumes, benefiting 145,000 colleagues at a cost of about $110 million. I'm proud to say that not one employee at HCA Healthcare has been laid off or furloughed due to the pandemic. The HCA Hope Fund raised $4.5 million this quarter, an unprecedented level of contributions from our employees, board, and the First Foundation. This year, the fund has provided nearly $2 million in grants to employees needing emergency support. Our mission is to care for and enhance human life, which revolves around both our patients and our employees. We truly care like family. Today, HCA Healthcare is caring for over 33,000 COVID-19 inpatients, including over 5,000 currently in-house. Throughout this pandemic, we have developed more capabilities to address this crisis, increasing our confidence in managing resurgence and challenges in our communities. These capabilities include enhanced clinical management protocols for ventilated patients, increased lab testing capacity with 90% of COVID-19 results provided in under 48 hours, improved supply chain systems, and logistics management, distributing over 20 million pieces of personal protective equipment to caregivers. Furthermore, we rapidly developed applications for managing capacity, increasing telemedicine offerings; completing over 500,000 telemedicine visits this quarter, well above previous levels. Finally, we began various clinical research projects aimed at improving patient care moving forward. Now let me discuss the earnings report. Like the first quarter, our business faced significant limitations due to governmental policies that restricted elective procedures and mandated shelter-in-place measures. As many markets reopened in May, patient volumes began to recover as our teams executed their reboot plans. Over a two-week period, we observed sequential improvements across most categories, finishing the quarter with modest growth in admissions. Overall admissions were down nearly 13%. For April, we saw a 27% decline, May saw a 12% decline, and June ended with a slight 1% increase. Outpatient volumes also improved sequentially during the quarter but did not reach last year’s levels for any service, with emergency room visits and outpatient surgeries each down 33%. On the revenue side, two qualitative factors contributed to a 10% year-over-year increase in inpatient revenue per admission. First, patient acuity was higher with a 3% growth in case mix index, and second, payer mix improved, with commercial business comprising 28% of admissions compared to 26% last year. Consequently, inpatient revenue was down only about 4%. Outpatient revenue declined 30%, and total revenue decreased 12% compared to last year’s second quarter. Our financial results were generally better and broader than we anticipated, but we believe it’s too early to make decisive statements about the future or provide guidance for the remainder of the year. As we navigate these remarkable times, we remain aware of our mission and the uncertainties regarding the broader economic recovery, uninsured rates, government regulations, state budgets, and the pandemic's resurgence and duration. In my comments last quarter, I mentioned the three-stage cost reduction plan we developed for the different scenarios we projected. During the second quarter, we implemented many first and some second stage items, and our teams executed these plans masterfully. For the quarter, salaries and benefits, supplies, and other operating expenses collectively declined approximately 11% compared to the previous year. We reported pre-tax government stimulus income from the CARES Act of $822 million, further reducing expenses and increasing diluted earnings per share by $1.73. Overall, our performance surpassed expectations, with diluted earnings per share reaching $3.16, a 46% increase from the second quarter last year. We continue to monitor the macroeconomic factors that impact our business. As the year progresses and we gain greater insight into these factors and our company’s performance, we hope to better assess the capital and operational decisions made earlier in the pandemic. Currently, we are facing a resurgence of COVID-19 in many of our communities, particularly in Texas and Florida. We decided to suspend elective procedures where appropriate in both states to free up capacity and staffing while conserving PPE. We are actively working with state and local governments to coordinate community-wide efforts. So far, we have managed the situation while providing necessary non-elective care to non-COVID patients. I reiterated last quarter my confidence in our teams' abilities to adapt operations, and they have once again proven their ability to rise to the challenge and deliver results. We are fortunate to have such capable teams, and I am confident they will continue to meet the needs of all our stakeholders. Although the second quarter felt lengthy to me—91 days—I am once more reminded of the incredible and resilient organization we have, driven by a shared commitment to do what’s right for others. As I've highlighted today, we accomplished much during this time across multiple facets of our business. I believe these achievements will position us well for long-term success and continue the great legacy of HCA Healthcare. Now, let me hand the call over to Bill Rutherford for more details on our financial results.

Thank you, Sam, and good morning, everyone. Let me provide some additional information on the quarter. As we expected, the second quarter saw progressive improvement each month of the quarter as we evolved from the initial response phase early in the quarter and then entered the reboot phase during the second half of the quarter. We saw an improvement from the middle of April, which was our low volume point throughout the quarter, in most every volume statistic. Our same facility admissions declined 12.8% in the quarter compared to the prior year period, and the monthly progression as Sam mentioned in his comments on admissions occurred with most of our key volume indicators. Same facility inpatient surgeries declined 15.7% in the quarter, with April declining about 38%, May was down 12%, and June was up 3% over the prior year. Same facility hospital-based outpatient surgeries were down about 27% in the quarter, with April down about 65%, May down about 19%, and June was up 4% from the prior year. Our outpatient surgeries in our ambulatory surgery centers were down about 40% in the quarter, with April down 85%, May down 32%, and June was up 1% over the prior year. Our teams did an incredible job of managing our cost structure during this period of significant volume and revenue fluctuation during the quarter. We began adjusting most of our discretionary and variable expenses in late March and April, when the volume declines were most pronounced. We were able to sustain many of the expense improvements throughout the quarter as the volumes began to improve in May and June. As reflected in our financial statements, our reported revenues declined about $1.5 billion, or 12.2% in the quarter from the prior year period. Our salaries and benefits, supplies, and other operating expenses collectively declined approximately $1.1 billion, or 10.5% during the quarter compared to the prior year. This is a testament to our management teams across the company and highlights our ability to adequately adjust to the sudden volume declines as well as efficiently serve the increased volumes we saw during the reboot phase. Let me highlight a couple of other important items in the quarter starting with the CARES Act. As we discussed last quarter, the company is very appreciative of the government's recognition of the significant impact this pandemic has had on healthcare providers across the country. As I alluded to previously, our revenue was significantly impacted during the quarter due to this pandemic and the subsequent stopping of most elective procedures. In addition, we experienced significant costs in the preparation and response phase, including our pandemic pay program, other employee assistance efforts, as well as securing adequate supply chain items. We believe the CARES Act funding was developed to account for this volume disruption and to offset some of these costs, both of which began impacting us in the first quarter and to ensure healthcare providers across the country could continue to offer critical services to the communities they serve. As noted in our release and financial statements, we recognized $822 million of government stimulus income from the CARES Act during the quarter. This equates to about $590 million on an after-tax basis. As of June 30th, we had received approximately $1.4 billion of CARES Act stimulus funding. This included about $920 million from the general distribution and about $450 million from certain targeted distributions for rural and safety-net hospitals, as well as hotspot funding. We have not recognized any of the targeted distributions in our P&L as of June 30th, as we are still performing the required analysis and attestation process. The evaluation period and guidance related to the relief fund continue to evolve, and as a result, we’ve recognized $822 million of the $920 million in general distribution funds received in the quarter. Subsequent to June 30th, we’ve received approximately $300 million in additional targeted distribution funds. Before I conclude, let me speak briefly to some cash flow balance sheet and liquidity metrics. As we mentioned in our first quarter call, the company took a number of measures early in this pandemic cycle, including entering into a $2 billion short-term credit facility, suspending our share repurchase program and quarterly dividend, as well as reducing planned capital expenditures. These were in addition to a number of operational adjustments we mentioned earlier. All of these efforts have enhanced the company's liquidity and capability to manage through these uncertain times. As of June 30th, 2020, the company had $7.7 billion of capacity under our credit facilities and $4.6 billion of cash on the balance sheet. Our debt to EBITDA leverage was 2.7x as of June 30th, 2020, after netting out our cash on the balance sheet. Cash flow from operations was $8.72 billion for the quarter, which includes the following components. We received approximately $4.4 billion in advanced Medicare payments during the quarter. These amounts are scheduled to be repaid over an eight-month period, beginning in August 2020. Cash flow from operations was also fairly impacted by the approximate $1.4 billion of CARES Act funding received during the quarter, I mentioned earlier, as well as the deferral of estimated income tax payments to the third quarter of approximately $200 million and payroll tax deferrals that will be paid in late 2021 and 2022 of approximately $200 million. As we mentioned in our first quarter call, we’ve reduced the company's planned capital expenditures. At this point, we anticipate reducing our capital spending to approximately $2.8 billion to $3 billion for 2020, as compared to our original plan of approximately $4.2 billion for the year. This remains subject to further evaluation of operating trends and opportunities. In short, we believe the steps that we implemented have enhanced the company's financial flexibility as we navigate these unprecedented times. We continue to believe the strength, scale, and resiliency of HCA are longstanding and critical attributes that served us well, not only during this past quarter but will continue to serve us as we go through the future cycles of this pandemic. So, with that, let me turn the call over to Mark and we'll open it up for Q&A.

Okay, well thank you, Bill. We will now start the question and answer session. Ian, would you please give instructions to those who would like to get into the queue?

Thanks. Good morning. I wanted to ask about decremental margins and what you're seeing in the COVID-affected period going into late June and July. I appreciate the insights. The decremental margins were very strong this quarter, only down about 30%. I'm curious if you believe that's sustainable moving forward. Additionally, can you provide some information on what's happening in Florida and Texas from late June into July regarding volumes and payer mix? We've noticed a significant increase in COVID cases in those areas. Thank you.

Hey, good morning, Justin. So, let me start with that and I'll pass Sam to add in. So, as we mentioned, I think the acuity of the patients that returned were higher than they were pre-pandemic. As we saw some of our higher acuity patients in cardiology, neurosciences, and orthopedics returned. And the lower acuity patients were maybe the ones that will take a little bit longer to return. In addition, we had favorable kind of ICU and NICU days. There was a high that contributed to the acuity. And so, I do think that the margin generations of those higher acuity patients as they return were higher than normal and what they were pre-pandemic. As we mentioned throughout our prepared remarks, we're very pleased with the response of our operating teams and the efforts we are able to make around discretionary costs and managing the variable cost. And we're very pleased with how we finished the quarter on that. Sam, do you want to give any comments on going forward?

Well, let me speak to Texas and Florida. Those are the two states where we have seen COVID-19 resurgence at its greatest level. We have other components of our company where we are seeing COVID volumes, but they're not to the level that we had seen in Texas and are seeing in Florida. In Texas which was a little bit ahead of Florida, if you will, with respect to the resurgence. I think the company has done an incredible job at responding to the needs of our communities, as have our competitors. And I think it's a testament to the healthcare system in the country and its ability to respond to these challenges from one place to the other. What we've seen in Texas is that our volume for COVID patients has peaked and actually started to decline. Whereas in Florida, we've seen a flattening out and a very modest growth rate over the last week. And we hope Florida is maybe a week behind what's going on inside of Texas. In total, our activity levels are up slightly in July as compared to June with respect to overall inpatient census. Clearly with our decision to restrict elective care to manage our response to the community, we have seen a slowdown in surgical activities. But we anticipate recovering that at some point in the future as we get better visibility into the COVID cases in the different communities. Our teams have done an incredible job, as I mentioned in my comments. Our physicians have supported our teams incredibly well. And then our corporate and other teams have made capabilities available to our institutions, allowing us to respond very appropriately. So, I'm really pleased with our outcomes. And we do believe that we're going to have to manage through COVID again. It's not something that's going to go away necessarily. But our ability to scale up, scale down, scale up, I think has now been proven. We've gained greater confidence in our ability to run our business and at the same time respond to surges. And so, the execution and the agility that our facilities and our teams have showed over this period of time helps us in developing learnings that we will be able to advance as we go forward on into this year.

Hi, thank you. Really impressive expense management in the quarter. It's really commendable. I guess I just want to follow up a little bit and understand what you're saying. I think I understand that too. So, if we look at this improving trajectory of revenue and volume through the quarter. And we get to July, you're saying inpatient census is up but I guess COVID is fueling some of that. And surgical volume is down. Is that really, I mean, just really happening sort of in Texas and Florida and not in the hotspots? Is there diversity of that experience even in those states? And then when we look at the rest of the portfolio that perhaps isn't being as hit by the resurgence as much. Are you still generally seeing an improving trajectory out of June into July? So, I guess we're trying to get at is there any sort of pent-up demand that's now diminishing or is it really just the virus that's causing some of the surgical activity to slowdown in some of those hotspots?

All right, thanks, Gary. Well, we have not restricted elective procedures or surgeries in markets where we don't have a need to respond to COVID. So obviously, in Texas, it started out in Houston in the Valley and those were the first markets where we implemented our elective procedure decisions. Then as it expanded to San Antonio, we replicated that in that market so it’s sequenced based upon the circumstances and it will unsequence if you will, based upon the circumstances. So, in Dallas, for example, which is not as significantly impacted by COVID, we've started to relax some of our procedure requirements and restrictions in order to deal with the circumstances in those communities. So, we're going to see some natural ebb and flow in Florida similarly and then if we were to see it somewhere else, we would use those experiences that we learned in Texas, in Miami as an example, to manage the situation. And this is what we're required to do with respect to our responsibilities as community infrastructure. We take it seriously and we think we've been able to prove to ourselves and prove to the community that we can respond effectively to the needs of our patients whatever COVID does surface at a level that’s much greater than what we were seeing in April and May. And we had some of this activity in June in some markets where we had COVID surge going on. It wasn’t as hot profile as what it was in Texas and Florida. Again, we were managing through that within our portfolio similarly in learning from that Gary and putting those learnings into our experiences now. And I'm confident that we will continue to learn and gain greater capabilities in managing the volume requirements in the ups and downs of this particular pandemic.

Hi, everybody. Yes, great job on the crazy quarter. Maybe just ask about the backlog or the pent-up demand, I don't know whether there’s any way that you're able to assess maybe through your doctor practices what that looks like, is that something that's going to go through the rest of the year? Could that spill over into next year? And there's been discussion about rebuilding a new pipeline not just working through the backlog; can you talk about your sense of people doing the primary care and to build the case backlog for surgeries in orthopedics and all that stuff? And then if I could just slip one other in, Bill mentioned the CapEx decline, can you comment on what, where you're pulling back on CapEx and should we assume that you’ll have to do more next year as a result of pulling back this year or these things that will permanently go away? Thanks.

Okay, A.J. it’s Sam. Thank you for the question. What I'll give you some observations. It's really difficult for us to pinpoint precisely what's going on in these circumstances. But we believe that approximately 40% to 50% of the deferred cases during the six to seven week period where most of our company was restricted on what we can do have been recaptured. And by recaptured, I mean either done or scheduled. So, the other 40% to 50% that hasn't been recaptured, we don't have visibility into the timing of that yet. Our physicians continue to build back their practices just as we're building back our business in a way that should hopefully recapture some of that gap that I just mentioned, but we don't have great visibility into that as of yet. What I will tell you also is that our ambulatory surgery centers were slower in their ramp-up because they were at a complete stop versus our hospitals, which were continuing to run during the pandemic period. And so, they have ramped a little bit slower as Bill alluded to in his comment. What we saw within our surgery was procedures, orthopedic, spine, general surgery recovered quicker and stronger. We also saw a slower recovery in our GI procedures and certain diagnostic categories, which started to ramp significantly at the end of June, which gives us a belief that downstream those diagnostic patients and encounters will ultimately require some level of therapy, whether it's surgery or something else. So, we have some insights into it. We believe we'll need through the third quarter probably through the fourth quarter to have a better sense of what the full recapture was of the cases that were in fact deferred. In cardiology, components of our cardiology business recovered really well, mainly electrophysiology and the procedures in that particular category. So, we had a mixed bag of events in the second quarter. And there are some indications of decent recovery in certain service lines, still more to come in others, and we will continue to monitor and try to gain insights from within our physician practices, whether they're affiliated or employed and within the different markets that we think are more advanced in their recovery period than others. And let that inform some of our observations further as we go into this next quarter.

Yes, AJ, this is Bill. We think it was prudent at the time to reduce our capital spending, as we talked about last quarter, and updated on this quarter, most of those projects were either deferral or slowing down some activity that was in the pipeline, as well as some deferral of our IT capital. We don't believe any of those decisions have compromised the strategic or growth initiative for us at this point. Actually during the quarter, we turned on a couple of projects that we felt there were compelling opportunities out there. As far as next year, we'll have to see what the marketplace and the environment is. I don't think just because we deferred these, that we'll have to substantially increase over what we ordinarily would have planned, but we'll continue to evaluate that as we go through these different cycles.

Good morning, guys. Thanks for taking my questions and excellent job in a very challenging environment to the whole team over at HCA. So, the question here is actually on the cost control side. You walked us through the revenue ramp throughout the quarter, but can you walk us through the sustainability, the cost control leverage that you put in place in April and March, and if the June positive revenues continue into July and the third quarter. How should we think about the cost controls you put in place?

Yes, Pito, this is Bill. Let me give a start to that. I think generally speaking, we can hold much of the cost controls that we put in place, as we said, most of those were around adjusting some of our discretionary spending, as well as some of the variable costs, like as Sam mentioned in his comments. We do know this recent COVID surge, we have to make sure we have the appropriate labor to serve that surge that may result in some increased use of either contract or premium labor. But I think as a whole, our teams have done a nice job. We continue to have opportunities to continue to look at other discretionary spending that we have. So, I think we've got a little bit of a track record of being able to manage to the environment, manage to the revenue that we have. We're very pleased with the results and we'll just have to see how the volume returns. And what are the variable costs that we're going to need to support that. But we feel for the most part, we can hold much of the expense adjustments that we made during the quarter.

Hey, thanks for the question. I was hoping I could get an update on the competitive landscape and maybe the potential for some M&A in the future. I know the industry is obviously working very collaboratively right now. But are you seeing any health systems that will be attractive partners for HCA struggling at all? And do you think you'll have more shots on goal from an M&A standpoint as you look out over the next one or two years?

Thank you, Matt. This is Sam, Matt. I don't know that we have any insights yet—market insights into competitor issues or opportunities that might exist. I think everybody is scrambling in many markets to deal with COVID-19 and discharge their responsibilities appropriately. And the likelihood of any strategic decisions being made during this particular period in time I think is probably not that high. We will continue to explore. We have a very robust pipeline for outpatient facility development and/or acquisitions that we're very excited about. And they're complementary of our existing networks. And we'll continue to look for adjacencies within that platform, as it relates to new market opportunities, and so forth, I would just have to be, I think aware and open to those but very conservative and appropriate in how we think about them. And capital allocation, as Bill just alluded to in our planning. I don't know though, at this point in time that we're going to see anything in the short run. I think it's going to take systems a while to get through this period and then start to determine what their appropriate steps are. But as we've done in the past, we have been opportunistic, with respect to certain acquisitions. And we will continue to maintain that philosophy and appropriately move forward.

Hey, thanks. Good morning. Maybe it's too early to tell. But any color around payer mix, and then any help on any internally developed framework to think about what the impact could be on HCA going forward? I mean I know you've had a lot of time to address this. And just wanted to get an updated view because my sense is that you're probably not seeing any meaningful change. And, I guess call it your core payer mix now. And maybe just an update on your self-pay and balance after reserve. Just where those are?

Yes, this is Bill. As we mentioned in the payer mix, we did see some favorable in the payer mix as our commercial declines were a little less than our Medicare declines, which makes sense that the Medicare population may take a little bit longer time to return to a healthcare facility. Our uninsured volumes remained consistent with our overall volumes that we haven't seen any material kind of differential with our self-pay volume. Going forward, that's obviously an area that we're paying attention to. We're doing a lot of study market by market to track various factors, whether that be unemployment or coverage. I think it is too early to be able to predict how that may unfold. But clearly, some of those factors will contribute to some of the uncertainty as we face the future. And factor into some of our decision. But we haven't seen a play out right now. But as we go forward, it's an area that we continue to monitor. And we have some data that we're trying to track to give us some insight as we go into our 2021 planning cycle.

Great, thanks. Good morning, everybody. So now, generally speaking, I think most investors have been thinking about 2Q,'20 likely being a trough for the hospital industry profitability, then sequential improvements in 3Q and 4Q. And I guess my question is if we just ignore the stimulus money and look at your strong $1.85 billion of operational EBITDA generated in 2Q just operationally. Should the investment community generally assume that operational EBITDA will continue to improve sequentially, at least in 3Q from the $1.85 billion base that we see things right now? And despite the fluid situations in Florida and Texas, are the two to make that call right now, just on the quarterly cadence?

Yes, Steven. This is Bill. Let me try. I think the reality is there are still many unknowns relative to the duration and impact this pandemic will have. One of the reasons we cannot update our guidance at this point. It's unclear the longer-term macroeconomic impact of how this might change the overall landscape including patient behavior, the economy, employment and coverage and alike. So, these are kind of somewhat unprecedented times for so it's really hard to really project on a quarter by quarter basis what we might see. What we do know is that we've demonstrated and I think as we demonstrated in this quarter, we have plans in place to respond, I think, to a range of scenarios that might unfold. And we have different stages of management actions based on how either volume returns or what that makes may be and alike. So, we'll continue to assess the market, let you know what we're seeing as we go through the year. But right now, we're just unable to convert that to any type of financial guidance going forward, and we just have to wait to see how the marketplace unfolds.

Thanks. I guess just try to go back to the pace and timing of volumes and like you guys obviously operate in a lot of different markets across the country. I don't know if you have any experience about markets that maybe got hit a little bit earlier from COVID and have since rebounded and whether the elective procedures coming back are coming back a lot quicker in those markets or if it's more balanced? I guess in the past you've given some data about procedures by the different regions that you guys or divisions that you guys have maybe color there, and maybe as far as June goes, how many of those 14 are kind of at or above where they were because it sounds like June rolls up, but what percent of those regions you're seeing above average volumes?

So here's how we looked at the recovery, we baselined everything off of April and we looked at May and June and highlighted within our portfolio what the revenue growth was in each of those months vis-a-vis April. And for the most part, we had remarkably consistent performance across the divisions with the exception of a couple of spots. Those two spots were out West in California primarily and then, in Miami secondarily. And that was because of releasing the restrictions a little bit slower in parts of California than Texas and Tennessee and places like that as an example and then Miami was dealing with COVID in a totally different scenario and their restrictions were released a little bit differently. But within those two brackets, most of our divisions ramped reasonably consistent as it relates to their revenue growth over April. And so, that's how we judged it, again it's very difficult for us to get very specific observations from one category to the other within procedures and so forth but looking at the revenue recovery as the better metric, we were able to see remarkable consistency across the rest of the company with respect to gains over April.

Good morning. It sounds like in your comments that you really are more prepared as an enterprise for ebbs and flows and COVID volumes. And I'm just curious do you think that plays out with doctors, with physicians as well as patients in that over time if we do have another flare up in the fall of that? I mean, basically we all become more desensitized as we figure out how to operate in the whipsaws that we see become less noticeable in the future. And I guess related to that, you did talk about on this current surge an increase in things like premium labor, contracted labor and alike. Maybe just any color you can tell us about general profitability of these COVID patients. Are they; Is it actually a profitable business when you bring it in? And then last just any DC perspective, Bill made some comments about the funding you receive and yet you've got lost revenue and higher costs. Any thoughts around additional relief funding for the hospital industry? Thanks.

Yes, so Frank let me speak to the ability to respond downsize, upsize, and respond again. I think we've proven to ourselves, as I mentioned, an ability to manage through that operationally as a facility and as a company. Also think many government—state governments have learned how to respond and to dial up, dial down maybe some of their policies. I think this is my judgment only, those individuals understand how to dial up, dial down their social activities in a way that is responsive to what's going on in their communities as well. So, I think all of this is creating a bit of muscle memory, if you will, with respect to COVID-19. It's our belief that we're going to have to maintain that memory, use that memory again and be able to deal with the potential flare-off that might occur until we have a vaccine or a different kind of therapeutic remedy that would allow for less COVID activity in our communities. So, I think it's not just us; it's policies, it's business, it's individuals, all taking advantage of these learnings and applying them to the situations that we believe will still exist in the future until there is some vaccine.

Yes, Frank, I think it's too early to talk about the profitability of COVID patients. What we do know early on is that our COVID patients that we saw did have a generally a higher acuity than our typical medical patient, just given a longer length of stay, a higher proportion in intensive care units. So, and there were some add-on payments by Medicare, as we know, but it's too early to really convert that to profitability. Our focus is really making sure that we've got all the resources to be able to care for those patients.

Thanks. Good morning. First, just wanted to clarify, you said June inpatient admission was about 1% and July inpatient was running ahead or was that commentary just on Texas? And then more specifically on the ER volume, I know down 33%, what are some of the initiatives you're working on to get maybe people more comfortable to come in, if any, and then you've been talking for a while on access points and increasing those access points. Where are you with that and how does the backdrop sort of change or accelerate that? Thanks.

Thank you, Ralph. So, what I mentioned—this is Sam—what I mentioned on July was that our inpatient census was up over June. We haven't finished the month yet. So, it's difficult to say exactly where admissions are going to be. With respect to emergency room activity, again, we saw sequential improvement in the rate of decline in our emergency room business in the second quarter with June being down, maybe half of what it was down or a third less than what it was, down roughly 15% as opposed to a 40% decline, I think it was in April. So, we saw significant improvement, if you will, from the rate of decline. What we also saw inside of our emergency room business was greater acuity. We had similar to our inpatient, a bit business, greater acuity in our ER patients who visited our facilities and that yielded revenue per ER visit that was slightly above our expectations. So, the business that we're losing is the lower acute business, which you would expect. We saw within our freestanding emergency rooms slightly quicker ramp up than we did our hospital-based ERs. Again, some of that could be due to patient concerns with respect to COVID. We have a very aggressive campaign, both operationally from a patient safety standpoint, as well as a communication standpoint with our patients on demonstrating to them, the safe environment that they deserve when they come to one of our facilities. As it relates to developing our outpatient platform, in order to support our hospitals, we continue on that pathway. We think it's an important part of taking the care experience to the patient, creating a more efficient, and a better price point for them. And we will continue to invest in that platform. We currently have a number of our outpatient facilities that are reopening as a result of the COVID pandemic closures that took place. So, each week we opened more of what we had previously closed. We're not up to a 100% reopening of our freestanding ERs in some markets or urgent care centers and other markets. On top of that, we have telemedicine. We have, as I mentioned in my comments, developed rather quickly a telemedicine capability, which is critically important, we think, to furthering our access strategies for our patients and creating convenience for them and efficiency for our physicians. So, we will continue to invest in that and build capabilities that support that as a wraparound platform. So, I'm very encouraged about what we have done. I'm encouraged about what we're seeing in the recovery in these outpatient activities. And as we move forward, I anticipate that we will continue to develop these wraparound capabilities that support our facility, our hospitals in a way that make it easy for our patients. And then if they need deeper care, they can get more sophisticated and deeper care inside of our hospitals.

Hey, good morning. I'll add my congratulations. That's a remarkable job in an unprecedented situation. I'm curious, as we look at July and you've got at least temporarily some inpatient capacity constraints in Texas and Florida. Have you been able to either through flexing capacity or moving things to outpatient? Have you been able to move material amount of maybe what would have been an inpatient elective a year ago into a different setting? Or is it kind of looked like it did before?

Thanks, John. Well, I think—this is Sam again—what we have done with capacity management to deal with COVID is quite remarkable. We've developed technology capabilities to give us real-time insights into our patient population, into every bed in the facility at any point in time. Also, giving us an indication of their clinical condition allowing us to think about and work with their physician to possibly place them in different settings. That has allowed us to increase the throughput in many respects, versus what we were able to do in the past. So, that's an outgrowth of what happened during COVID that we think is going to create value for our patients, create better use of our assets in the future and create more value for our payer partners in the future as well. The other thing that we've done during COVID is we have been able to, what we call level load patients across our network. And by that, I mean getting patients into the right facility, even when we know we're going to have a pressure point at a particular facility because of the community issues that are going on. So, moving patients to where we had staffing or moving patients to where we had beds was another piece of capabilities. I think we advanced. We do that all the time with Hurricane, as we deal with hurricanes. But we took our hurricane learnings and applied that to COVID situations where we had stress. The area where we've seen slight acceleration of inpatient to outpatient over what we saw pre-COVID is in some of our surgical cases, mainly orthopedic total joints, where there was a natural progression of inpatient to outpatient. It's slightly higher post-COVID than it was pre-COVID. It's not significantly higher, but it is higher. And is that something that's going to continue? We believe that it will be there. We anticipated in our planning, our multiyear planning those orthopedic total joints would continue to migrate to more outpatient activity. But we're built for that. We collaborated with our physicians on making sure that we're dealing with the patient in the proper setting. We have an ambulatory surgery center platform, that if that's the best setting, they can go to that. So, we have prepared ourselves for this migration. Outside of total joints, I wouldn't submit that there's anything material that's taken place. That's been part of our overall capacity management. It needs to be clinically driven, not capacity driven. And as long as it's clinically effective for the patient and will support that and hopefully accomplish that in a way that's productive for the capacity and at the same time appropriate for the patient.

Hi, thanks and appreciate the work you did, but also taking the question here. So, mine on the CARES Act funding, you received, I think, a total of $1.4 billion plus an additional $300 million after the quarter. You recognize $822 million. And I understand the difference between the general distributions of $920 million and then the more targeted what seems like $750 million or so. So, I guess the question is do you think you're going to be able to actually recognize even that incremental $100 million or $98 million of the general distribution, or any of the targeted distributions? You're just not seeing that level of impact either volumes or costs?

Yes, Joshua. This is Bill. Let me try to highlight that. As you might know, the terms and conditions and general guidance for these funds continue to evolve and update. And for the most part, you have a 90 day or longer period to go through an analysis and attestation process. And we're in the middle of our analysis and validation procedures for those funds right now. So, it's really too early to talk about when and how much we might recognize in the future. We continue to monitor the guidance that comes out from various government agencies and we continue to do our analysis for the targeted funds. We have till mid to late third quarter or even July in the fourth quarter. So, we'll continue our analysis and go forward and we'll discuss really what that results when we go through future periods.

Hi, thanks. And thanks for fitting me in here. I've just had one other CARES question as well and just relating to the Medicare advance payments that you and the others have received at the industry. And I know those payments are supposed to get started to get paid back in August and over the course of eight months. Obviously, still a lot of virus impact and it seems like a lot of other hospitals in the industry are facing a lot of financial pressure still. So just interested if you're hearing any or you have any line of discussions with CMS in terms of them maybe looking to delay in terms of when facilities are required to start repaying those Medicare advance funding that was paid out of 2Q.

Yes, Scott. This is Bill. I know there's been some discussion, but I don't have any insight into how those have progressed. As you probably know, it's scheduled to be repaid and offset against Medicare claims in the future beginning in August. So, we'll just have to see what that cadence goes. But I know there's been some discussion, we read about some potential altering how those funds and what the time period may be. But I don't have any insight on what ultimately may come from those discussions.

All right, Scott. Thank you for the question. Appreciate it. All right. Listen, thank you. I want to thank everybody who joined us today and participated on the call. As always, we're here to answer any of your questions. And so, take care. Have a good day and be safe. Thank you.