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InvestorDay2008Transcript_FINAL1 InvestorDay2008Transcript_FINAL1 Document Transcript

  • TENET INVESTOR DAY June 3, 2008 WELCOME Tom Rice Senior Vice President, Investor Relations Oh, welcome, everyone. And thanks for quieting down so quickly; this is a great group. You must all be excited to get started today; we’re very excited as well. This is Tenet’s 2008 Investor Day. My name’s Tom Rice. I run the Investor Relations Program at Tenet. I have one small duty to do before we get in. Let me just take you through this slide very quickly. Tenet management will be making forward-looking statements this morning and this afternoon. These statements are based on management’s current expectation and are subject to risk and uncertainties that may cause these forward-looking statements to be materially incorrect. Certain of those risks and uncertainties are discussed in Tenet’s filings with the Securities and Exchange Commission, including the company’s Form 10-K and its quarterly reports on Form 10-Q. Management will be referring to certain financial measures, such as EBITDA, which are not calculated according to GAAP. Management recommends that you focus on the GAAP numbers as the best indicator of financial performance. These alternative measures are provided as a supplemental aid in the analysis of the company. So with that, I’d like to introduce Tenet’s President and Chief Executor Officer, Trevor Fetter. OPERATIONS OVERVIEW Trevor Fetter President and Chief Executive Officer Thank you, Tom. Good morning, everyone. Welcome to Dallas. We’re delighted to have you here; very excited to tell our story this morning and give you a deeper understanding of our business and our strategy. Let’s go back for a moment to last year. Last year I told you that we had the right strategy, the right programs, a highly capable team of leaders, and a strong understanding of what we needed to accomplish. I think you’ll hear and see throughout the day that we accomplished the main thing that we intended to do, and that was to put the company back on a growth track. We passed an inflection point in our turnaround sometime between 12 and 18 months ago.
  • Tenet 2008 Investor Day Page 2 And by the way, just to get it out right at the beginning of the day, I’m pleased to tell you that the only substantive change that we’re going to make today to our outlook is a positive one. Biggs will describe at the end of the day why we are raising our estimates for the year-end cash balance. Okay. So here’s my message for this morning. Tenet’s culture and values are driving measurable improvements in operations and performance, and driving innovation to capture industry opportunities and to mitigate the headwinds. Let me break this down into three parts. First, we’ve made powerful changes in Tenet’s culture and values over the past few years. You’re going to gain an understanding of that and its importance during the course of today. Second, this has enabled us to make measurable improvements in performance and operational effectiveness, passing the inflection point that I mentioned a minute ago. What we’re doing is sustainable, and it’s long-term oriented. I’ll talk about how we’re innovating in a variety of areas in our business. And third, I’m going to talk about how all these factors enable us to deal with the current opportunities and challenges in the industry environment. I’d like to describe our culture and values because they’re so important to understanding our business. Our leaders are managing for today and for the long term. We’re running the business as if we own the business. Everyone that you meet today is evaluated on the same set of metrics, although the goals are different depending on the different business units. The metrics are part of our balance scorecard which we developed five years ago. This team understands that clinical quality is good for our patients and good for our shareholders. As a company, we are managing through insight and a deep understanding of the data and facts. We’re now able to collect all of that information. Over the past several years we’ve invested in systems to report the data to enable our fact-based approach. And most importantly, as you’ll hear throughout the day, our focus on the customer has grown tremendously. In fact, Steve Newman and others are going to explain Tenet’s strategies through the eyes of our customers – in this case, a physician and a patient. Next are the improvements that we’ve achieved in operational effectiveness and financial performance. Now, on our quarterly calls, you’ve heard us discuss basic issues of operational effectiveness, like volume building, managing our pricing, and maintaining control over costs. We usually discuss these in the context of that particular quarter’s results. Today we’re going to expand beyond that context. For example, you’ll see how we’ve developed greater insight and coordination in managed care contracting. We’ve been very careful about our approach to pricing and very strategic about delivering value to our customers at the managed care companies.
  • Tenet 2008 Investor Day Page 3 We now understand the revenue cycle better than ever, and over the past five years we’ve quietly been reengineering major segments of that part of our business. Our physician relationships and recruiting efforts are much more aligned with real market issues and opportunities. This was a weakness of ours as recently as 2005, but we’ve come a long way and we’ve been very strong in 2007 and 2008. Our management turnover is lower than at any time in the last five years, providing a much needed sense of consistency among our hospital leadership teams. You’ll notice that we’ve made enormous changes to our hospital portfolio in the past five years, cutting the number of hospitals by more than half. But that was not the point. The point was to strengthen the company. So we got out of the rural business. We reduced our exposure to the weakest and most seismically-challenged California hospitals, reducing our footprint in California by more than half. And California is now much more of a source of strength for the company than a source of risk that it was several years ago. Philadelphia is also now a source of strength for the company, and I’ll bet that many of you who’ve followed us for a long time thought you’d never hear me say that. We’ve got one-third the beds that we had in Philadelphia as recently as three years ago, but our two hospitals there are very competitive and performing well. We trimmed our position in Florida by 20 percent, and we now concentrate on the hospitals that have a bright future in that state. I hope you’ve noticed that on our recent earnings calls we no longer have to say, “but for Florida” or “but for Philadelphia” when we explain our trends. Our efforts on portfolio management haven’t been just about cutting. In the same period of time we opened three new hospitals, we have another one under construction, and we acquired a hospital. And speaking of new hospitals, our newest hospital, in El Paso, Texas, is off to a great start after being open just two weeks as of tomorrow. So let me give you some specific examples of improvements in performance. This slide shows our EBITDA and EBITDA margins since the beginning of 2006, adjusted for items like litigation charges, and it’s also presented on a same-hospital basis. On the left, in the beginning of 2006, our EBITDA was less burdened by bad debt than it is today; bad debt was 90 basis points lower. And it was boosted by stronger admissions than we have today; the admissions were about half a percentage point higher. We also had a more favorable patient mix. But since then we’ve reduced our unit cost and we’ve improved pricing, so that we could achieve a stronger bottom line despite lower volumes and higher bad debt. It’s pretty tough to grow earnings in an environment like we’ve had for the past two years, but now, as we’re growing volumes, we’re much better positioned to capture the operating leverage that we have in our business. I mentioned that I believe we passed the inflection point leading to sustainable, profitable growth between 12 and 18 months ago. This slide shows that since the third quarter of 2006, we’ve had a consistent trend of improving EBITDA and improving EBITDA margins. In Q1 2008, for example, our same-hospital adjusted EBITDA grew by 23
  • Tenet 2008 Investor Day Page 4 percent, and the margin exceeded 10 percent. Now, we did this in spite of weak volumes, and the key has been solid pricing growth and excellent cost control. And while this EBITDA margin is still below our industry peers and our own longer-term outlook, several of you who followed the company for a while probably thought these levels would never be possible. The key to maximizing the economic potential of our business lies in utilizing our capacity, which is primarily hospital beds, to a greater extent. That’s why you’ve seen our strategies emphasize growing profitable service lines, and bringing more physicians on to our medical staff. So looking at volumes, total same-hospital admissions are shown by the blue line. We crossed into positive territory in Q4 2007, improved upon that in the first quarter of 2008 to a solid 1 percent growth, which was the second-best number among our peer companies. And so far into Q2, we are improving upon that number. Through May, admissions are up 1.4 percent, and in the month of May, admissions were right around breakeven, which Biggs will explain further. By excluding charity and uninsured admissions to create a metric of paying admissions, you get a better view of the strength of our admissions trends. In Q1, growth in paying admissions was 1.2 percent, and so far in Q2 through May, that 1.2 percent trend is holding firm. Wall Street’s attention is understandably focused on commercial volumes, but you’ve got to remember that we do earn an attractive contribution margin on the noncommercial pieces of our business, including government programs. Finally, look at the trend in outpatient growth. While it’s still negative, the trend is up sharply since 2006, and so far in Q2, we’re just below breakeven, at negative 0.6 percent. As I mentioned, we’ve been very strategic about pricing. We have better information than ever before, a better case for quality than ever before, and a smaller but much stronger portfolio of hospitals than before. And that has driven our strong result in pricing. We’ve entered into several new large agreements just in the past year which should drive solid pricing and visibility. Among them: UnitedHealthcare, Aetna, CIGNA, Blue Cross of California, and then most recently Independence Blue Cross of Pennsylvania. In this two-year period the results of our managed care contracting efforts have been reflected in strong pricing growth. The growth rate since 2006 for inpatient pricing has remained around 4 percent. Growth in outpatient pricing has been 10 percent, but it’s more recently moderated to closer to 7 percent, but still a very strong number. Clint Hailey is going to tell you more about our managed care strategies for 2007 and 2008, but they’re basically to get all of our hospitals in the networks, the major payers, to add to Tenet’s positions to these networks, and to continue to add pay-for-performance incentives based on clinical quality. We’re delivering superior value to our customers, and we want to be recognized for that.
  • Tenet 2008 Investor Day Page 5 Now, while we’ve driven strong growth in pricing, we’ve also held cost increases to some of the lowest levels in the industry. This chart shows Controllable Expenses per Adjusted Patient Day on a same-hospital basis. The average rate of cost increases over the past two years has been 4.7 percent. Excluding an accrual in Q4 that pushed the reported number to 5.1 percent, we’ve been at or below that two-year average for more than a year now, and that’s without much growth in volume. Once we generate greater volume growth, our cost discipline is likely to serve as a solid source of margin expansion. Cost discipline is now wired into the culture that I spoke about at the outset. One area we don’t talk about enough is the revenue cycle. Out of necessity, we were early innovators in this area. Beginning in 2004, we launched a major effort to consolidate, standardize, and add innovative tools to our revenue cycle. This includes consolidating all our Medicare business into one national center; consolidating our regional business offices into four regional insurance centers; consolidating our self-pay collection activities into one center; being the first in the industry to move away from pricing based on gross charges for uninsured patients; and launching telephone-based Patient Access Centers to do preregistration and financial clearance before patients ever reach the hospitals for scheduled procedures. You’re going to hear more about these innovations, as well as things like patient-friendly services such as automated registration kiosks, simplified billing, and online payment, later this morning. But these initiatives have enabled us to have stable bad-debt expense as a percent of revenue, including better performance recently than our outlook of 6.5 to 7 percent. The revenue cycle innovations have also enabled us to improve collection rates across all payer categories during 2007. This chart compares Q1 2007 to Q1 2008. This is a pretty remarkable performance, given the horror stories that you’ve heard across our industry about bad debt expense. On the Q407 call, Biggs introduced some major efforts in 2008 to increase the efficiency of our balance sheet; we’ve made a lot of progress already. Just to give you a brief update, Jones Lange LaSalle sent marketing materials on our medical office buildings, that portfolio, to several hundred prospective buyers three weeks ago. Prospective buyers are already conducting due diligence on Broadlane in a process that’s being run by Citigroup. We announced a letter of intent to sell our two hospitals on the campus of the University of Southern California. And we announced yesterday the sale of three small hospitals in California, including one that we had held for sale for more than four years. I’d like to summarize by saying that we’re doing very well on this initiative so far. Moving on to the innovations that we’re driving to deal with the industry environment, as well as to grow value, I’m not going to dwell on these, because throughout the day you’re going to have an opportunity to hear about these strategies from the people who are actually leading their implementation. But I’m going to go into a little detail on four key strategies of ours. First is the Commitment To Quality; next, the Targeted Growth Initiative; third is our Physician Relationship Program; and finally, there’s our strategy regarding capital expenditures in our hospitals.
  • Tenet 2008 Investor Day Page 6 When we started our Commitment To Quality, our quality scores were below the national average and not improving. In the subsequent four-year period, we achieved a steep trajectory and steadily improved our clinical quality. We crossed over the national average for the first time in 2005, and the gap between our scores and the national average continues to widen. We reached a new high with our scores in the fourth quarter of 2007, at 90.8. We continue to have five times the national average rate of designations as Centers of Excellence by UnitedHealthcare. And our quality designations by CIGNA continue to grow; they’re currently at 199. This has become a real point of differentiation for our company. To put it in context, here you can see how we compare against the ten largest hospital systems in the country. During both the reporting period that is noted here Q206 to Q107, and more recently, what we have performed at in Q407. This slide demonstrates how our hospitals are using quality to distinguish themselves from their local competition, and other examples of this are scattered throughout the lobby outside of this room. This emphasis on quality is noticed by physicians, patients, and also even the local media. It’s not an advertisement as much as it is a way of reminding people what matters to our hospitals and to thank the physicians and caregivers who make it possible. Now a word about our Targeted Growth Initiative. The objective of TGI, as you know, is to grow targeted service lines. Targeted Growth Initiative is not entirely targeted towards commercially insured patients, but this slide shows that for that patient segment how the growth in the targeted service lines has been better than what we’ve seen in commercial admissions. Now, keep in mind, the commercial admissions have been negative throughout this period. But the widening of this gap indicates to us, at least preliminarily, that TGI is really working. Our Physician Relationship Program is designed to add high-quality physicians who practice in the targeted service lines to our medical staffs. We are succeeding in this effort with a 10 percent increase in our active medical staff since the beginning of 2007. We’ve also made very good progress in increasing the satisfaction of physicians and patients. This slide shows the percentage of physicians or patients who rate our hospitals in the top two categories on a five-category scale. We believe that physician and patient satisfaction, along with clinical quality, are leading indicators of volume growth. Now, a few years ago, several of you commented that we were constraining capital expenditures, and in 2004 that was a fair observation. We were coming off of a huge investment program that had taken place in 2001 and 2002, with a lot of carryover into 2003. I felt that we had to conserve cash in order to deal with the mountain of litigation that we were facing. But in recent years, we caught up. We implemented a capital stimulus program following our government settlement in 2006, and continued it through 2007. Now, our spending is at a rate that slightly exceeds the trailing average of our peer companies at about $40,000 per bed. Our outlook, at $600 to $650 million of capital spending, is in the same range as what we’ve done recently. But it calls for a level of capital spending that we believe will keep our hospitals fully competitive.
  • Tenet 2008 Investor Day Page 7 Turning now to the operating environment. Those of you who’ve known me for a while may recall that I’m an avid sailor and formerly an avid pilot, so occasionally I start mixing all these nautical metaphors. I’ve also been making a concerted effort to stop inducing motion sickness among analysts and shareholders, so I’ll try to keep this relatively simple. Like our industry partners, we continue to face tough headwinds. But we’re managing these headwinds by being great in quality and service, and offering these services at fair prices, by constraining costs, and trying to bring more patients in the door in our targeted service lines. Our consumer-oriented strategies are designed to deal with the tough economy, cost shifting to the consumer, and the rising number of people who are either uninsured or are basically taking most of the financial risk for their healthcare needs. These consumer-oriented strategies include what you’ll hear today about the revenue cycle, plus Commitment To Quality and Targeted Growth. And for a variety of macro and competitive reasons, volumes have been tough for nearly five years. Our Physician Relationship Program is helping to attack this program very directly. Now, fortunately, it’s not all headwinds; we’ve got some wind at our back. The U.S. population is aging, the prevalence of obesity and other disease states is increasing, and coverage for the uninsured is among the leading public policy issues, and favored by a majority of Americans. I think it will be a reality in the next five years, but of course, the devil will be in the details. So to briefly summarize, we passed an inflection point within the last year, to year and a half, on the road to sustainable profitable growth; our volume trends are positive; our pricing trends are strong; we’re exercising continued discipline around costs; our strategies to mitigate bad debt expense have proven effective; and we’re driving very hard on cash; leaning the balance sheet; and making good progress towards achieving Free Cash Flow. We remain confident in our strategies and their ability to generate profitable and sustainable growth. So before I wrap up, a few comments on what you’re going to hear today. Each year we do our best to bring a new perspective to our story. We’ll try to do that two ways this year. First, our regional leaders are going to share our story from their perspective. They’ll give you a deeper sense of the specific issues that we face in each market, and how we differentiate ourselves from our competitors. And second, because so many of you have asked us to walk through what happens during physician visits, or how we’re using TGI in database marketing to attract new patients, we’re going to tell you. And we’re going to make this story more real by focusing thematically on our most important customers: the physician and the patient. So throughout the day we’re going to refer to how they experience Tenet’s strategies. In the meantime, as you hear about our strategies, our programs, and our initiatives, I hope you’ll see how we’re using quality, service, and innovation to grow our business.
  • Tenet 2008 Investor Day Page 8 And by that, we mean, improving margins, cash flow, and return on invested capital, all in ways that are very consistent with the cultural values that I described at the outset. So with that, to get this rolling, I’d like to introduce our next speaker, Tenet’s Chief Operating Officer, Dr. Steve Newman. Though Steve has been in his current role for only a year and a half now, he continues to impress all of us with his energy and enthusiasm. He’s a guy with a real sense of urgency. In fact, are you wearing the button? Dr. Newman: It’s in my briefcase. Mr. Fetter: He’s making meaningful contributions to improving our operational effectiveness. I’m pleased to turn it over to him. Steve. (Applause) OPERATIONS OVERVIEW Steven Newman, M.D. Chief Operating Officer Well, thanks, Trevor. Good morning, everyone. It’s hard to believe it’s only been a year since our last Investor Day. But I’m here, and happy to report on the progress we’ve made towards sustainable, profitable growth since last year’s Investor Day. As Trevor mentioned, we continue to focus on operational excellence, quality, innovation, and cost controls, to position our company for future success. We’ve also made real movement in moving toward a retail orientation in this era of consumerism, and those themes should be carried throughout today’s program. At last year’s Investor Day, I laid out several strategies aimed at improving our hospital’s performance. Today’s presentation is focused on providing an update on our progress and answering the questions that many of you have asked about how we’re working to attract physicians and patients to our hospitals. As you will remember, last year I laid out my prescription for success. I’m pleased to report that those priorities have now become “Tenet’s Prescription for Success.” We’ve communicated these focal points throughout the company, and embedded them in our Balance Scorecard for incentive compensation. In the next few minutes, I want to share with you exactly how the elements of the prescription have materially impacted the operations and financial results of our company. I’ll also show you where we’re going as we accelerate our progress to attain our overall goals of improving quality, service, and shareholder value. Along the way, I’ll profile the fundamental expertise, operational structure, and discipline we’ve established. So let’s begin with the dramatic successes we’ve achieved in clinical quality. At the top of our list of priorities was “Improved Clinical Outcomes.” Obviously, we’ve invested in
  • Tenet 2008 Investor Day Page 9 systems, people, and software to measure and improve our clinical quality. Over the last year, we’ve accelerated this focus, and it’s paying big dividends for us in several ways. As Trevor mentioned, our CMS Core Measures, as reported on the Hospital Compare website, continue to improve, and we’re beginning to see tangible financial returns on this major investment in quality. You’ll hear more about the payoff from our quality achievements throughout the day. Our quality scores are the raw material for our Physician Relationship Program sales teams and the driver for our hospitals to earn “must have status” when our managed care teams negotiate with our commercial payers, but we’re also receiving direct payments for our quality scores. Clint Hailey, our head of managed care, will talk about this in more detail later this afternoon, but it’s important to note that three of our largest commercial managed care payers are going to pay our hospital incremental dollars for achieving mutually agreed upon clinical and other performance-based measures, including patient satisfaction. Our next step along this path is expanding our quality focus to include a clinical research arm, which means an additional source of revenue for both Tenet and the physicians on our medical staff. This is a major factor in attracting new physicians to join our medical staffs. Prescription number two is to grow both inpatient and outpatient volumes consistent with our TGI priorities. The key to volume growth is to focus on the customers, who, in our case, include both physicians and patients. Over the past year, we focused on identifying the right physicians who aligned with our business strategies, and then differentiating ourselves so they in turn become Tenet enthusiasts. We’ve also focused our efforts on attracting patients, and assuring they have a quality experience within our hospitals. As this diagram shows, to win over our customers, we’ve continued to implement initiatives around quality, people, adding technology, and the managed care strategy, which our presenters will all touch on in the course of today. I want to say a word about our outpatient services. As you know, outpatient services is a highly competitive business. However, we believe we’re uniquely positioned to succeed in this area due to our quality service and outcomes, operating efficiency, and industry leading throughput times, which patients and physicians are increasingly demanding in this era of consumerism. In Q1 2008, our total freestanding Ambulatory Surgery Center volume grew 8.2 percent, and total diagnostic imaging center volume grew 2 percent. This was aided by Tenet’s Managed Care Department, which negotiated national contracts with the inclusion of our freestanding Ambulatory Surgery and Diagnostic Imaging Centers, with automatic annual escalators. Tenet’s Outpatient Team has been working with our Patient Financial Services group and Information Technology Department to streamline the scheduling and patient registration process for the competitive outpatient service market.
  • Tenet 2008 Investor Day Page 10 To fuel our growth in outpatient services, we opened two Diagnostic Imaging Centers in 2007, and are in the process of building three Diagnostic Imaging Centers to be opened in 2008. We’ve also purchased two Ambulatory Surgery Centers, one of which was in financial distress. This center is located in Orange County, California, and is called the Reagan Street Ambulatory Surgery Center. It has turned into a success story after being purchased from 31 physicians last year. As this slide indicates, our management of the center has improved volumes by 37 percent in Q1 2008 over Q1 2007. First quarter cash collections also exceeded the prior year by 57 percent, largely due to Tenet’s Patient Financial Services developing a dedicated billing and collections center for Reagan Street. As you know, there’s a significant investment being made in outpatient services across the country, which we believe is creating overcapacity. As centers like Reagan Street become available in our target markets, we believe we can use our core competencies to replicate the success we’ve achieved in Orange County throughout the country. As Trevor mentioned, we received a number of questions from you about how our strategies fit together. For instance, how does our physician recruitment program work? How do families living near our hospitals learn of the services we provide? So throughout the day, we’ve developed presentations outlining our strategies, programs, and initiatives, from the perspectives of our customers: our physicians and our patients. And to help you follow our story from these two perspectives, let me introduce you to some individuals whose archetypal stories will help make the Tenet strategies come alive. These are not real individuals, but they represent those our hospitals see every day. First, let me introduce Dr. Cogan, a physician who formerly practiced at a Tenet hospital. Dr. Cogan only recently came back to Tenet as his hospital of choice. But why did he come back? Primarily because our Commitment To Quality has helped to improve our reputation within the communities we serve. And second, because we actively reached out to engage Dr. Cogan in a conversation through our Physician Relationship Program. A little later this morning, you will hear from John Landino about how this process actually works. Second, let me introduce the Ramirez family, who live in a community near one of our hospitals. Although Mrs. Ramirez was experiencing uncomfortable sensations in her legs, she didn’t have it investigated until she received a mailer from a Tenet hospital. You’ll hear more about how she became our patient from Trish Brainerd, who will walk you through Mrs. Ramirez’ patient experience later today. Let me emphasize that throughout the day, please remember that a fundamental strategy for enhanced financial returns is growth in inpatient and outpatient volumes, and the strategies and infrastructures are in place today to do that in a sustainable fashion. Well, let’s turn to prescription number three. Over the last year, we’ve achieved a significant improvement in our unacceptably high staff turnover rates. We’ve piloted and implemented several programs across the company to address this important issue. For instance, the Versant nurse residency program, to orient, support, and retain first-year,
  • Tenet 2008 Investor Day Page 11 new-graduate RNs, has been piloted at five hospitals. And we’re preparing to kick off the Nurse Residency Program at eight additional facilities over the next three months. The new Nursing Balanced Scorecard that we implemented since last Investor Day is also an integral part of our efforts at reducing nursing staff turnover. Our core Chief Nursing Officer metrics for the scorecard are based on our Five Pillars of Quality, Service, People, Cost and Growth, all which align with Tenet’s overall strategy. I should also mention that we’re engaged in rolling out frontline leadership training throughout the company, to make our supervisors better leaders – not just managers – at that all- important interface at the bedside. As a result of decreased turnover, we have recently seen significant drops in contract labor, especially among RNs. The chart on the right shows our progress in reducing nurse turnover. This creates a healthier work environment for all our clinicians, including lab technicians, pharmacists, and other medical personnel. This improved retention of high-quality professional staff meets one of the four objectives of “Tenet’s Prescription for Success,” and made a meaningful contribution to our strength in EBITDA in Q1 2008. Now, let’s spend some time talking about physicians, physician relations, and physician recruitment strategies. First, let’s examine just why recruiting and retaining our active staff physicians is so critically important to our success. As we mentioned earlier, Dr. Cogan was one of those physicians who was alarmed by the investigations and allegations against Tenet in 2002 and 2003. He and other physicians began to hedge their bets by using their admitting privileges at non-Tenet hospitals. While Dr. Cogan actually severed his relationship with his Tenet hospital, many other physicians, referred to as splitters, kept their Tenet relationship, but gradually increased their utilization of competitor hospitals, at Tenet’s expense. This sort of bet hedging continued in an unabated manner until the Global settlement and subsequent capital infusions occurred in the summer of 2006; hence the former “Physician Sales and Service Program” was born. As initially conceived, PSSP’s mission focused on these splitter physicians. Those of you who have followed the Tenet story for some time will recall that we were quite hopeful that the announcement of the Department of Justice settlement and the acceleration of our capital spending would be sufficient to reverse this splitter behavior and the adverse impact it had on our patient volumes. While the PSSP program addressed the issues of the splitter physicians, it did not result in a complete resolution of Tenet’s problems of eroding volume. As 2006 came to a close, Tenet hospitals, in the aggregate, were still struggling with the problem of declining volumes; something more needed to be done. In early 2007, it became clear that we needed to view the volume issue more broadly. For example, in Florida, the active medical staffs of our hospitals shrunk by 10 to 40 percent between 2002 and 2006. We then examined in detail the medical staff sizes at all 55 hospitals and found that in all but 10 hospitals, the normal attrition of physicians had not been effectively offset by ongoing physician recruitment, redirection, and relocation,
  • Tenet 2008 Investor Day Page 12 which are all critical elements in maintaining healthy and productive medical staff. It was clear we needed to rejuvenate our approach to the complex issue of physician staff pipeline. This slide shows that our hospitals fall into four categories, with only a minority having made progress in growing their staffs over that important four-year time period. Not surprisingly, the hospitals with the greatest erosion in active staff also had the greatest volume declines during this period. What’s surprising is how tight this link between staff size and volume really is. In the 11 hospitals where medical staff losses exceeded 20 percent, the decline in adjusted admissions was 20 percent. In the 13 hospitals which incurred staff losses of 10 to 20 percent, adjusted admissions declined by 8 percent. In the 13 hospitals that lost zero to 10 percent of staff, they experienced a 3 percent loss in their adjusted admissions. And finally, the 10 hospitals that successfully grew their medical staffs during this time period saw an aggregate 3 percent growth in adjusted admissions. The data told an unmistakable story: In addition to the need to solve our splitter challenge, we learned we needed to replenish our pipeline and replace our physician base. Attrition in our medical staffs became the number one issue we had to address. The aggregated medical staff losses were the missing link explaining the loss of inpatient admissions, and to a lesser extent, outpatient visit declines between 2003 and 2007. It then became obvious that the splitter physicians were an important but minority part of the story. This significant new insight led us to the dramatic expansion of staff in our newly refocused PSSP initiative, which was retooled and relaunched as PRP – the Physician Relationship Program. This retooling included a significant expansion of our marketing staff, as there was clearly no time to waste if we were to successfully offset the natural attrition of medical staff by onboarding new physicians. The factors driving this erosion are many and varied. Many of the underlying drivers flow directly to the lifestyle issues of our active staff, including retirement, untimely death, and sometimes frenetic relocation behaviors that unfortunately characterize so many segments of today’s highly mobile society. Now, you’re naturally asking why we allowed this to happen. Well, fundamentally, no excuse is really acceptable. But it’s fairly clear that the criminal trial in San Diego had a chilling effect on the entrepreneurial spirits of our hospitals’ A-Teams, and unwarranted excessive caution had undermined the actions required to maintain the healthy expansion of our medical staffs. Given this powerful insight into the dynamics of the physician pipeline, the path forward was clear. With the dramatically expanded new PRP program, and the education of our hospitals’ A-Teams, we took a page out of the playbook of big pharma and the device manufacturers and built our own homegrown sales and service curriculum. These actions have delivered immediate success. As Trevor mentioned, we added more than 1,250 active medical staff – net of attrition – since Q1 2007. While this concept is incredibly simple, it is extremely powerful and effective in explaining the loss of volume between 2003 and 2007. It also explains precisely why
  • Tenet 2008 Investor Day Page 13 we’re so excited about the potential of what’s been accomplished in the last five quarters, much of which has yet to be visible in our aggregate volume numbers. Let’s take a deeper look at this net addition of physicians last year. Let me limit the analysis to calendar 2007, as it’s more intuitive to talk about annual numbers; the extension through our first quarter results should then be fairly obvious. The net expansion of 1,086 to our staff, which we achieved in calendar year 2007, actually required the addition of 2,611 physicians. This very strong achievement of our PRP initiative was then partially offset by the loss of 1,525 physicians during the year, to give us a net growth of 1,086, an overall 9.3 percent growth rate in our active medical staff. Now, let’s look at what this means for volumes. What I find fascinating is that the implications for volume growth are very different in the short term than they are in the long term. And fortunately, what I just referred to as the long term really isn’t in some distant future. I’m referring to a time frame no more than 18 to 24 months out; in other words, a time frame close enough in that it should be highly relevant to today’s investors’ investment horizon. But I’m getting ahead of the story; let’s start with the short term. A short-term issue in 2007 was that the 2,611 physicians we added during the year admitted patients at a far lower average rate than the 1,525 physicians we lost. This shouldn’t be surprising at all; there are a variety of reasons why. Let me emphasize, I’m talking about the short term; a new physician relationship would yield a much lower set of volumes than those that recently departed. Here is the familiar productivity S-curve, which shows our expectations for the long-term volume potential of the physicians we’ve added to our medical staff. This graph helps demonstrate the potential impact on reported aggregate volumes as our relationship with these physicians matures. While we are sometimes successful in redirecting the entire volume of a mature physician’s practice to a Tenet hospital virtually overnight, results can sometimes go rather slowly for the first six months. It’s much more typical for these relationships to follow the classically shaped S-curve as the physician steadily gains confidence that his or her needs will be well served at the new Tenet hospital. Those relationships that eventually reach full maturity should do so over a 12- to 24-month time period. Subsequent volume growth will then be the result of PRP introducing incremental physicians to our hospitals. All right. Changing gears now, let’s move to the fourth item in our prescription for success: cost management. Trevor provided you a good window into the improvements we’ve achieved in operational performance. Our strong cost discipline, operating leverage, and innovative technologies are designed to deliver good performance in unit cost metrics. We’ve also made substantial progress in improving the overall cost structure of our hospitals, outpatient facilities, and support services. Productivity as measured by both FTEs per adjusted average daily census and same-hospital contract labor expense for adjusted patient day improved significantly.
  • Tenet 2008 Investor Day Page 14 As Richard Yonker will discuss later today, we also continue to do well in controlling supply costs by working on standardization. Throughout the remainder of the year, we will continue to roll out new and improved tools for our mangers to help them track productivity and improve throughput and efficiency through process redesign. We expect continued success in this area, which should contribute to margin expansion. In summary, we continue to move forward on all four elements of Tenet’s Prescription for Success, which has helped us to position our company well in our key markets and contributed to the progress we’ve made toward profitable, sustainable growth. All right. Thank you for your attention to that presentation. And now it’s my pleasure to introduce the business development and marketing section of today’s agenda. Last year we set out to expand our business intelligence systems and integrate all of our activities to identify, attract, and retain our most important customers: our physicians and our patients. Seeking a new perspective to accelerate our integration and implementation, we recruited Lloyd Mencinger, an executive with years of experience at Boston Scientific and Baxter. Now let me turn over the presentation to Lloyd and his team, to discuss business development and marketing. He will tell the story of how we translate the Targeted Growth Initiative in several of our proven strategies and tactics to focus on our customers – the physicians and patients – generating profitable volume growth for our company. Lloyd. BUSINESS DEVELOPMENT Lloyd Mencinger Vice President, Business Development All right. What we plan to do here today is to give you a picture of how our activities and various business developments fit together to grow volumes in a hospital. And we do that by picking up the two stories that Dr. Newman introduced earlier: that as a patient, Mrs. Ramirez, and as a physician, Dr. Cogan. And we’ll start with how we identified and made contact with Mrs. Ramirez, and all the marketing touch points along the way that resulted in her becoming a patient of ours. And similarly with Dr. Cogan, how we identified him, and all the activities that attracted him back to our hospital. And I would encourage you, as you listen to this, to think about what’s going on behind the scene. I know you hear a lot about our programs – TGI, Quality, Core Measures, PRP, PSSP, and some of them in general terms. But these scenarios of single patient, single physician, I think is a powerful way to see the real impact these programs make and how they all fit together. And after we go through those two scenarios, then we’ll pull back up and see what that implies in terms of the impact across the whole organization.
  • Tenet 2008 Investor Day Page 15 Now, to introduce the patient story, I will ask Trish Brainerd to come up. Trish is our Senior Director of Marketing. She’s been with Tenet for 17 years, and she’s done a terrific job in creating most of the programs that you’re going to hear about. Okay, Trish. Trish Brainerd Senior Director, Operations Marketing Thank you, Lloyd. Good morning. Please meet Imelda Ramirez. Imelda Ramirez is a 55-year-old corporate attorney living in South Florida. She’s in very good health, and she regularly plays tennis at a private club. Although she faithfully sees her gynecologist for annual well-woman checkups, she does not have a primary care physician. On the rare occasion when she gets a sore throat, she goes to the local urgent care center. Two years ago, she severely injured her ankle on the tennis court, and she was treated and released through the emergency department at a local Tenet hospital. She has UnitedHealthcare insurance through her employer. About a month ago she received a mailer from the Tenet hospital where she had her ankle injury. She rarely even reads the multitude of direct mail she receives, but she recognized the hospital’s logo, and remembered how well they treated her when she was in such pain for her ankle. The mailer invited her to a free screening for something called peripheral vascular disease, or PVD. She’d never even heard of this disease, but the mailer talked about some warning signs that resonated with her. It talked about how leg cramps after exercise could be a symptom, and also about skin color changes on the legs and feet. Now that she thought about it, sometimes after playing tennis, she had experienced cramping. And the skin discoloration she thought came from living too many years near the beach might also signal a problem she had not considered. She read that if this went unchecked, it could result in a heart attack or a stroke, so she decided to check it out. It was a Saturday, but she called the toll-free number anyway, expecting to get a recording. Happily, a live person answered the line and told her more about the screening. When she learned that a physician would interpret the results, she decided it was worth doing. She was surprised to learn the hospital had appointment dates two weeks, available on Saturday, so she booked an appointment. A few days later, she received this letter from the hospital confirming her appointment. The envelope also contained some administrative and screening exam forms she could complete at home and bring with her to save time. When she came home from work the Friday before the screening, she had a message reminding her of the screening time, giving her directions about where to park, and what door at the hospital to enter. When she checked her e-mail, she noticed they had also confirmed all the details in an e-mail.
  • Tenet 2008 Investor Day Page 16 On Saturday morning, she drove to the hospital and had her PVD screening. A vascular technician performed an ankle-brachial index exam, a blood pressure check on the arms and legs, and listened to her neck with a stethoscope. He treated her very professionally, and told her she would receive her results by mail within a few business days. She was in and out in 15 minutes. A few days later, she received a certified mail letter from the hospital that contained her results. The letter included the name of the physician who had interpreted the results and said they were severe, and that she should promptly be seen by a physician for more follow-up and testing. Later that day, the hospital also called her, to make sure she’d received the letter. She was shocked, and a little scared to learn she had strong symptoms of peripheral vascular disease. She was also really glad she’d received that mailer and taken advantage of the free screening. Her clinical results had been signed by a doctor named John Cogan. She looked him up in the phonebook and learned his office was about five miles from her home. Her husband was en route to the airport for a business trip, so she called her son Marco, to tell him about the screening and her results. While she was still on the phone with her son, Marco quickly Googled Dr. Cogan’s name, to see what he could find out about his credentials. First in the search results was a link to healthgrades.com. The next screen Marco saw contained an in-depth profile of Dr. Cogan, and it included a photograph, an overview of his practice, personal facts, professional affiliation information, and information about the health plans he accepts. Being very protective of his mom, and understanding the potentially serious nature of the disease, Marco was particularly relieved to see that there were no disciplinary actions against Dr. Cogan, and that a third party had verified his board certification. Marco saw that Dr. Cogan’s profile on HealthGrades was sponsored by the same Tenet hospital that had performed the PVD screening on his mom, so he knew this was a physician in good standing with a hospital his mother trusted. Since they knew from his HealthGrades profile that Dr. Cogan accepted his mom’s UnitedHealthcare insurance, Marco went ahead and clicked the “make an appointment” button, and furnished his mom’s e-mail address so the office could schedule their earliest available time to see her. During the office visit a few days later, Dr. Cogan diagnosed her with PVD, and he scheduled her for a balloon angioplasty at the Tenet hospital where she had received the screening. Six weeks after her procedure, Imelda was back on the tennis court, telling all her friends at the club about how much better she felt now that she didn’t have pain in her legs anymore. Ironically, her doubles partner, Melinda Mitchell, had just received a flyer for a similar screening at the Tenet hospital. This screening offered an EKG, a heart health assessment, blood test, blood pressure check, and body mass index evaluation, all for $39. Melinda was 57 and had never even thought about getting a cardiac evaluation. But when she told Imelda she was probably not going to respond to the offer, her friend became very animated and told her she simply must take the time to have a screening
  • Tenet 2008 Investor Day Page 17 because it might just save her life. She also told Melinda about how wonderful Dr. Cogan was. Melinda scheduled her EKG screening at the Tenet hospital, and now she too is a patient of Dr. Cogan. He performed some tests and gave her a clean bill of health, but he’s helping her make some lifestyle changes that will keep her that way for many years to come. Both Imelda and Melinda are quick to tell all their friends about the Tenet hospital that helped them find a physician they love and trust. Lloyd Mencinger Great. Thanks, Trish. So you have the story of the single patient, but behind that story, of course, is the story of the marketing strategy, the programs, the infrastructure that make all that work and bring it together. Now, let’s see what that looks like on the physician side, and we want to introduce Dr. Cogan. And to tell that story, we have John Landino. Now, John Landino is the Vice President of the Physician Relationship Program, and he comes with 22 years of medical device experience, including Medtronic and Huron. He’s been at Tenet for a year and a half, and during that time, he’s done a tremendous job building this program. So welcome, John. John Landino Vice President, Physician Relationship Program Thank you, Lloyd. All right. Let’s take a look behind the scenes at the science of what it takes in the Physician Relationship Program to bring a new Tenet physician around. Tenet’s South Florida Hospital has an active Physician Relations Program (PRP) managed by Kathy Myer, who joined the staff one year ago. Kathy’s previous job was as a physician account manager for a major medical device manufacturer, calling on doctors in the same service area as her Tenet hospital. She has been calling on many of the same physicians for many years, so her transition to Tenet’s Physician Relationship Program was very smooth and included compliance and ethics training, along with Tenet’s Core Physician Relationship Building module as part of her education. One of the things she likes best about her role at Tenet is targeting physicians with current affiliations to the medical staff who are splitters, and working to build additional referral volume to their facility. Even better, she enjoys targeting the ones who don’t have privileges but should. She considers it detective work, as she reviews the hospital’s manpower analysis and determines the specific physicians needed to support and grow her TGI service line.
  • Tenet 2008 Investor Day Page 18 She works her network and mines market intelligence on specific physicians and their practices. State data provides her with information on the specific types of cases performed by a physician, the hospitals where the physician does the cases, and even the payer mix of his or her patients. Payer databases, provided to her by Tenet’s Commercial Managed Care Department, help her identify physicians who have been designated as high performers by a particular health plan, with either premium designated or specialty statuses, based on high quality and proper utilization. Her goal is to identify physicians with a solid portfolio of commercially insured patients who perform the type of high-margin procedures and the services targeted for growth by TGI, and then align their practices with her hospital and get them added to her hospital’s medical staff with active credentials for admitting patients. This in-market recruitment of physicians and the redirection of their patient practices have been keys to growing her hospital’s volume, and targeting Dr. Cogan for active privileges is typical of the PRP strategy. The hospital’s cardiac and vascular programs have been identified as key expansion areas. The demographics of their service area show good growth in the age cohorts who need cardiac treatment, and their market share has been growing for the past three years. They’ve recruited highly skilled cardiac nurses and technicians, and have invested nearly $2 million in cardiac technology, including the construction of a new Cath Lab that will be equipped with the latest technology: bi-plane, dual, high-resolution detectors with real-time image processing, including 3-D and cross-sectional views, digital flat-panel screens, digital-subtracted angiography that is cardiac-capable, and electrophysiology. She culls the list of potential cardiovascular physicians down to three, and determines that Dr. John Cogan is at the top of her target list. His practice is less than ten miles from the hospital, so she knows his travel time won’t be a barrier. He’s Harvard-trained and board certified. And he’s only been out of school for 15 years, which tells her he’s experienced, yet savvy to the benefits of the latest technology. Aetna, one of the hospital’s best commercial payers, has given him their EXCEL Top-Performing Specialty Physician designation. So he’s well regarded by the plan for high quality and good utilization. He’s also received a Premium designated status with UnitedHealthcare, which measures the same metrics. State data indicates he’s taking most of his Aetna and UnitedHealthcare patients to a competitor, and that competitor does not have United’s Cardiac Center of Excellence designation, so this gives her an exclusive benefit to present to Dr. Cogan. She also notes her hospital has just hired the former Cardiac Cath Lab Director, so Dr. Cogan will already know and trust one of her key clinicians. After speaking with her Cath Lab Director and learning more about Dr. Cogan, everything from his preferred time to block scheduling to the fact that his kids go to the same school as her CEO’s, she books an appointment and takes her Cath Lab Director with her. She strategically presents the hospitals features and benefits that will resonate with Dr. Cogan and help him build his practice. Dr. Cogan is pleasant, and he has great rapport with the Cath Lab Director. However, he’s a very busy physician with a growing
  • Tenet 2008 Investor Day Page 19 practice, and he doesn’t currently have a compelling reason to change hospitals. He’s happy enough with the way the competitor treats him, and his patients like it there, so he won’t commit to learning more about her hospital. He does, however, agree to keep the door open, and she promises to come back to see him again. Before she leaves, she schedules a return appointment in two months. At this appointment, Kathy brings research and clinical papers with her that she knows would interest him. One was a clinical study on the great outcomes being realized by hospitals that are using the very same new Cath Lab technologies being installed in her hospital. Another one discussed groundbreaking new surgical techniques being used in conjunction with the same new technology going into her hospital. And the paper was published by one of her key physicians, under whom Dr. Cogan trained. Her plan was to demonstrate the more favorable results seen with these new techniques and equipment, which his hospital does not have, and begin building key differentiations favorably positioning her hospital over the one at which he currently works. She tested the opportunity to gauge his interest in joining her hospital’s medical staff, and he said he would think about it. While he was not quite ready to make a commitment, he was, though, greatly impressed with Kathy and that she had listened to him in their first meeting, remembered where and with whom he trained, found out what his teaching professor was currently doing, and returned with a copy of his research work. When she suggested as a next step, a visit to the hospital that would include a private tour of the new lab, meeting the CEO and his A-Team, including a lunch, he readily agreed, and she coordinated his schedule with her CEO’s to get it confirmed. Two months later, the new Cath Lab is nearing completion, and Dr. Cogan is coming in for a tour. Kathy and the A-Team carefully plan every aspect of his visit, and the entire clinical staff in the vascular and cardiac areas were shown his photo and asked to treat him as a VIP. Knowing they have a very short window of opportunity to maximize his visit, the A-Team is fully prepared to discuss with him the features and benefits for having him want to practice at their hospital. On the tour, the CEO pointed out the quality posters, highlighting the core measure scores against those of their competitors. Kathy could tell it made a strong impact when Dr. Cogan saw that her hospital outscored the hospital where he did most of his work by nearly 10 percent. They also showed him their superior HCAP scores, demonstrating their focus on patient satisfaction. The CEO tied both indicators back to their UnitedHealthcare Center of Excellence designation, and Dr. Cogan was starting to see the very clear competitive advantage in quality. These very important quality factors directly impact Dr. Cogan and his payer status by helping him to continue receiving the Premium Quality designations from United and EXCEL Top-Performing Specialty Physician ranking from Aetna. He toured the Cath Lab, and Kathy was really proud of the way the staff went out of their way to genuinely welcome him to their home. The new equipment was truly impressive, and she could tell he was glad he came. He even mentioned calling his training professor to further discuss the new surgical techniques he was pioneering. Over lunch, the CEO
  • Tenet 2008 Investor Day Page 20 discussed the hospital’s strategic business initiatives and how well they aligned with Dr. Cogan’s. This was the first time a CEO had actually engaged him in a strategy discussion, and he had many questions, all of which were answered. This was a place that would help give his patients the very best care. This was a place that made him feel respected and important, where he could expand his skills in an environment that invested in state-of-the-future technology. And this was a place that understood physicians, and recognized them as their most important constituents. When asked by the CEO for a commitment, Dr. Cogan made up his mind then and there. He decided to give them a test drive and to apply for privileges at the hospital and to begin admitting some patients. He was subsequently credentialed and onboard. He was also impressed by how the other cardiac and vascular physicians welcomed him. The chief-of-staff even called him. And Kathy was there every step of the way, making sure that everything worked and happened on time. She even brought his office manager to the hospital for a full orientation and tour. This manager now regularly attends quarterly office manager luncheons, to learn about hospital services and key people who make their jobs easier. And Kathy uses these opportunities to network her among her peers at the primary care physician offices. The hospital Marketing Department signed him up for a community lecture, and placed ads in the paper with his photo, promoting the event. Forty-five people attended, and two of them became new patients. The hospital sponsored his profile on the HealthGrade site, where commercially insured patients research information about physicians. He’s been very impressed by the number of new patients in his practice who say they found him on the HealthGrade site, just like Mrs. Ramirez. He was also impressed by the hospital’s wellness outreach and their focus on building a healthy community. He’s since participated in two health screenings, one for PVD and one for a cardiac risk assessment, and he is always surprised by how many patients above the age of 50 do not yet have a physician. He senses a definite focus on physicians at the Tenet hospital. He feels a true partnership there, and they have an understanding of what it is like to be a physician in today’s complex healthcare environment. Their focus on patient satisfaction keeps his patients happy, and that makes his job a lot easier. He is seeing a lot more commercially insured patients, and his practice is growing. More importantly for Kathy’s hospital, Dr. Cogan has now shifted most of his volume to Tenet. When considering where he and his practice is today, he’s sure glad he came on that tour with Kathy. Thank you. Lloyd Mencinger All right. Thanks, John. That’s great. I think you’ll agree that these scenarios are powerful, and they make very tangible how these different processes fit and work together and reinforce each other. So what I’d like to do now is give you a little picture of
  • Tenet 2008 Investor Day Page 21 behind the curtain – we’ll give some numbers as well – and look at a few processes inside the business development that are making those stories happen. Okay. These are the elements of business development: Physician Relationship Program, which is John and what he just went through; Physician Recruiting; marketing; and the call center. I’ll start with John’s, the PRP program. You are all very familiar with these numbers, so these are our admissions growth. What I’d like to do is overlay onto this our buildup of our Physician Relationship Program rep team. That’s what that looks like. Now, that represents, as Dr. Newman mentioned earlier, a strategic commitment to this Physician Relationship strategy. These are the Kathy Myers and the Dr. Cogan story. Now let’s layer in the volume growth attributable only to those physicians called on by that team; and there you have it. Now, essentially, John and I have a combined 50 years’ experience in medical device, and especially sales and marketing, serving the exact same customers that we serve now at Tenet. When we first plotted this chart, we just looked at each other; it was instant pattern recognition. We said, “Look, we have seen this movie before many times.” And in medical device, as many of you know very well, if you have a competitive product offering and a strong field organization made up of people like the Kathy Myers – dedicated, skilled, understands the physician customer deeply, knows how to match up what we offer to his needs, and helps him be successful in his practice – if you have a team like that in medical device, you win; you drive growth, and you beat the competition. We always used to say, “Whoever has the best army wins,” and we believe that that’s exactly what we’re seeing here. Now, another factor that’s working in our favor on this is that back in 2006, besides having a smaller field team, we were dealing with more issues, so more of the customer contact was about issues. Now that’s dramatically changed, and the center of gravity today of our efforts of that team is really focused on growth. Now, this is interesting, because to help validate that what we talked about before isn’t just happenstance or a correlation but is true causation, we essentially had a controlled experiment. And some hospitals have TGI lines that line up with the diseases of the geriatric population – cardiac and neuro, etcetera – and they have targeted on building relationships with nursing home medical directors and administrators, and they have also followed the formula of dedicated, well-trained experienced reps, and you can see the results. Now, the beauty of this, at least as we talk inside here, is that for pharma and medical device, this has been 25, 30 years; but for hospitals, it’s relatively new. So we can leverage both a relatively early mover advantage, and also leverage best practices to accelerate execution. And I think that’s just what has happened here, and John deserves a huge amount of credit for helping make this happen. Now, if you take one more step of cause and effect – and we’re talking strong teams drive volume – one step upstream from that, what drives capable teams? It’s training. The success of these programs are directly related to the skill levels of the people on the team.
  • Tenet 2008 Investor Day Page 22 And again, taking a page from device and pharma, they do an unparalleled amount of this training; it never ends. So we have a strong commitment to a robust training strategy. Now, phase one really started in 2007, and the focus was on the Physician Relationship reps. And what’s fascinating, John would tell me stories about these early classes, and people would come to these classes and then they would go back to the hospital, then all of a sudden you’d see an uptick in volume from those hospitals. So the good news is there is opportunity, and as people learned new skills, they were applying them. Now, phase two of the training came with the realization that there are so many touch points between us, in the hospital, and our physician customers that we need to expand the training through all the departments. So you can see here, the CNO training, operations managers, nurse managers, outpatient, ASCs, etcetera. Now, the one on the bottom, the Gen 2.0 Core Training, that really reflects our desire to raise the bar for the PRP team. The best demonstrated practice for training is that the top people, the top performers in the field deliver the training; it’s not just like a training group. So that’s kind of where we want to go; that’s our aspiration, moving in that direction. Okay, let’s talk about Physician Recruiting. Now, just to remind you, the PRP program focuses on physicians that are already in our service area, for the most part. Physician Recruiting is talking about bringing physicians in from outside of our market. Okay. Following Dr. Newman’s comments earlier on the need to build our physician pipeline, the takeaway for this slide is that there’s a dramatically increased focus across the organization on building our internal recruiting capabilities. The message is similar to the PRP slide. The ten people back there, the ten people there in Q107, they are mostly people spending some part of their time on recruiting, not full-time. And recruiting is different. I mean, you have to work on the weekends, you work at night, it’s 60 percent of the time recruiting their spouse. So the whole notion of experienced, dedicated, well-trained people make the difference here, and it’s no surprise. Now, there has been a heavy investment already, at every level – hospital, region, corporate. The region SVPs have been making a lot of progress on this, on the recruiters and also the physician pipeline. At corporate, we’ve hired a Director of Physician Recruiting. Bob Smith, the SVP of Central, has led an approach to recruit at physician conferences, and it looks very promising. They’ve done five so far, so we want to learn from him and continue this thing going, and we’re going to get 30 targeted for the rest of the year. We’re building a program to recruit medical residents and fellows. We’re looking at a physician database so we can be more efficient in our placements. And we’ll be launching training for our recruiters in Q3, so as the graph moves to the right, you can see it becomes more fully dedicated.
  • Tenet 2008 Investor Day Page 23 Okay. Now let’s move into Trish’s area, marketing and the call center. As you saw with Mrs. Ramirez’ peripheral vascular disease screening, there are just many marketing issues and many ways that we touch the customer. But the most effective ones, what they have in common, is a call to action, and that’s that red circle. So some way they can call in, or through the Web connect into us. Now, what’s great about this is once they call in, we put them into our database. So every month we match it to discharge data at the hospital, so we’re able to track, ultimately, how that much net revenue is driven by each of these programs and track the ROI. So let me show you what the economics look like here. Okay. The top line is those contacts coming into the call center. So look at, in Q108, you can see the 57,000. Now, the yellow line there is the net revenue associated with that. And if you look at that vertical climb there, in Q4 to Q1, what’s happening is that every time we do a marketing campaign, Trish’s team does a debrief: they analyze the targeting, they look at different data cohorts, they say, could it have been aligned better with TGI? So they’re in a kind of continuous improvement loop on better segmentation, better targeting, and more effective marketing. And you can see how then, in 2007 the net revenue total was $408 million, but if you look at that run rate, $122 million for Q1, we’re running quite hot for next year, so I’m sure it’ll be something above that. All right. As an example here, the top is the total number of screened patients, and that continues to go up, even as the line down in the blue, the hospital participation, even as that varies. So what’s happening is we’re getting this alignment, a better, more effective marketing and targeting, so that only those hospitals that will really benefit will focus on any program. Some of the things we’re looking at in targeting: disease states with large, undiagnosed populations – of course, the pie charts on the top; prior patients’ medical criteria lines up with undiagnosed disease; commercially insured aligned with hospital TGI; Premium designated physicians. So we’re going down the list and moving toward deeper segmentation, more profitable segmentation, higher ROI in these programs. Okay. This is HealthGrades that you’ve heard about; Mrs. Ramirez found and looked up Dr. Cogan, and you see how traffic continues to grow. HealthGrades is the number one site to find information about a physician. And our arrangement provides detailed reports for Tenet physicians to a consumer for free, and pretty much for the other physicians they cost around $30, so we have a differential advantage there, and there is a lot of interest. We get about – I think the key number for contacts would be about 20 million connects, but that yellow line is really the physician profiles opened. So there is an interest; there’s 4.3 million cumulatives since we started. And click into a “make an appointment” button, and we have about 125,000 people make an appointment with a Tenet physician each month. And the demographic is exactly what we want: well-educated, high-income, 63 percent female and 30 to 65 age cohort. Now, this next one is – we talked about the call center, but this is quite interesting, because it illustrates that our call center is so effective that it has an external business that’s growing 27 percent. And we service 22 healthcare companies, and this is
  • Tenet 2008 Investor Day Page 24 something actually we’re going to valuate as we go forward. But we have a strong capability there that’s built up over time. Okay. This is just to illustrate that we are now looking across all our channels, and we want to make sure that we have an appropriate strategy for each of these channels. Now, we talked about two: there’s Dr. Cogan would be the specialty physician, and Ms. Ramirez is the patient. And of course, consumer can be segmented – there are infinite segmentations possible, and there will be a lot of talk about segmentation later. But this is the focus of our next phase in marketing, deeper segmentation, more profitable segmentation. And this is just to illustrate that for our core channels; you know, our core customers, as Dr. Newman mentioned – the PCP, the specialist, and the consumer – we have robust suites of marketing initiatives either currently active or in the works. So to close on this, this is a snapshot of where we were and where we’re going. I’m not sure if that is exactly the perfect terminology, but we are focused on things that will impact the business right now. So where we’re going isn’t some three years out, it’s far less than that, actually. So we’re things that are in the works today; we’re not talking things beyond yet. So if you look at where we were to where we’re going on the PRP, so it’s from a relatively new team to experienced, highly skilled, and bigger team; from first-round sales training to now expanding that out; Gen 2, and expanding out to the entire organization; physician recruiting, part-time recruiters to a more increased, dedicated head count at the hospital region and HQ level; and in terms of residents and fellow recruiting program, launching that Q4, I believe; and recruiting at 30-plus physician conferences. That’s just this year. Marketing. From the core marketing we talked about to, again, deeper segmentation; and on the call center, we want to get the call center involved further into recruiting as well, physician recruiting, and we’ll take a look at the MEDContact. So to close it out, as you’ve seen, I think, the programs that we’ve shown you, they have momentum. We know they’re delivering on both the volume and the cost side. And they’re delivering for the Dr. Cogans and the Mrs. Ramirezes as well. And the focus now for us is making sure that we execute on these fully to drive the growth. Steven Newman, M.D. I want to thank the team for giving our visitors and investors today a deeper insight into how the pieces and parts of our strategies and tactics fit together to generate a positive impact with respect to our most important customers: our physicians and our doctors. I think it’s quite exciting that about 75 percent of what you saw presented has been accomplished and expanded since the last Investor Day in June of last year. And that gives me great confidence in terms of our growth of the business in the coming quarters and years.
  • Tenet 2008 Investor Day Page 25 So with that, I’d like to ask you to engage with us in a question and answer session. Any of the items that we talked about in my presentation as well as the Business Development and Marketing presentation are open for discussion, and there are microphones that Val and Tamara will pass out. So please wait for the microphone so that we can all hear you question and we won’t have to repeat those. So, Adam, wait one second; Val will bring you the microphone. Q&A Session Q. Okay. Adam Feinstein with Lehman Brothers. If you could just elaborate – in the opening, you talked about the volume growth through May. Maybe if you could just provide more commentary, because obviously we knew the April numbers when you guys came out with earnings. So just curious, just any additional commentary you can provide about the volumes. And then my second question is on the recruiting side. Maybe if you could just provide a little bit more commentary about the mix between specialties, as you think about the ramp-up there. Thank you. A. (Dr. Newman) Sure. With respect to our admission volumes and outpatient volumes, we’ve always said that the results from week to week and month to month will be lumpy and bumpy and open to many variables, including how many weekdays there are in the month, how many weekend days there are in the month. And those, in terms of the impact on plus or minus around that breakeven point are very substantive. So if one accounts for the fact that in the month of May there was one less weekday than there was in the same month in 2007, one clearly normalizes to a slightly positive month for us. And we saw those variations in the April numbers, the March numbers, the first quarter numbers. And I think from your perspective, we should be looking at longer-term trends. Whether it’s a quarter or a year. I think our trend in terms of admission volumes is undeniable. If you go back six quarters, as Trevor showed in his presentation, the trend is up, the curve is up. The only question is the rate of gain, and the results will speak for themselves over time. In the meantime, we grow the pipeline. And hopefully, through the presentations this morning, you saw our deeper understanding of what really drives that business in terms of the targeted growth admissions and outpatient visits we want, and what we’re doing specifically to create that channel. That will provide the sort of growth we need to take advantage of our operating leverage and to improve our margin over time. With respect to physician recruitment, the second part of your question, that’s really a mix across the company; it’s very different. For example, if you look at the central region, Bob Smith has created – what he’ll talk about – his 501(a) system, it is mainly primary care physicians. That is driven by the fact that in those particular markets, many of the competitors have actually purchased or employed primary care base. We need to make sure that we have a
  • Tenet 2008 Investor Day Page 26 stable and growing primary care base to feed work to our specialists that tend to congregate around our campus. If you go to Florida and look, there would be a higher proportion of specialists than you would see in Texas, and the reason why is we have critical issues regarding emergency room coverage by specialists in Florida. For example, in Palm Beach County, we found it very difficult to provide urologic coverage, our gastroenterology coverage at our emergency rooms there, and we’ve gone to hiring some of those specialists. If you aggregate across the company, it’s about a 50-50 mix between primary care and specialists today. One of the factors that affects it, remember, is about 60 percent of our total employed physician bases in Philadelphia, in support of our two academic medical centers – hospitals, St. Christopher and Hahnemann University Hospital, where we have slightly more specialists than we have primary care physicians. Q. Good morning. Thank you. Sheryl Skolnick from CRT. Thanks for all the details; they were good. My first question is on a key issue that I don’t know if the Street’s made of it or the company’s made of the volume numbers has been the performance of the commercial managed care. And obviously, we’re all curious about that because it’s high margin, even though paying heads and the beds are clearly up, and that drives the bottom line. So the strategy of dealing with that, I understand, is to go after, through targeted growth initiative, those services that yield you the best outcome in terms of profitability, cash flow, performance of facility, etcetera. Right? And you show us the statistics on those physicians that you’ve targeted being up significantly more than those physicians you have not. So the question that I’m curious about is how much longer will it be, or what will it take for the overwhelmingly positive trend that you’re seeing in the targeted physician commercial managed care admissions to overwhelm the nontargeted that are clearly dragging you down? A. (Dr. Newman) Oh, that’s a great question. Let me just expand upon the point that you made about TGI and add one element to it. Remembering, you know, we’re targeting the best payers, we’re targeting the best margin. But we’re also targeting the services that will be demanded by the population over the next five- and ten-year horizons. So in some geographies we have a young population that will still be young in ten years. In others, they’re my age, and so they might be old in ten years. And so therefore, we might be targeting service lines that would have a disproportionate Medicare Advantage members. The other thing that we’re seeing is quite interesting. As commercial managed care has become more prevalent in the country, and as we hit the age wave where between now and 2010 the number of patients that become eligible for Medicare is increasing from 1.4 percent annually to 2.9 percent annually, we’re seeing commercial managed care patients age into that Medicare age group. They
  • Tenet 2008 Investor Day Page 27 preferentially desire to be in a Medicare Advantage plan as opposed to fee for service. So when we’re looking at paying heads and beds from our perspective, the fastest growing population is the Medicare Advantage plan. That also supports our targeted growth initiatives, especially in neurosciences, because some of those issues have to do with aneurisms and strokes, other sorts of cardio, cerebrovascular accidents, TIAs, things like that. So I think that it’s clear that commercial managed care is not the be-all and end- all for the growth of our business and the growth of our margin over time, although it is the number one sought-after prize – you might call it the holy grail – with respect to the payers we’re going after. Your question about how long will it take is really very difficult to speculate upon because so many other factors are affecting this. In some of the micro markets that we operate, we’ve seen economic downturn result in decrease in commercial managed care lives in that area. In other areas, like for example, El Paso or some of the southern states regions, we’re seeing business continue to grow; it seems to be resistant to the economic downturn. So commercial managed care is staying the same or stable. The other issue has to do with how effective commercial managed care is in controlling utilization, and shifting work from inpatient to outpatient. It’s a long way around to saying I don’t have the answer to your question, but you should feel comfortable that we have all the data points that we’re continuing to monitor on a regular basis, and we build that into our strategies to find even newer, more innovative ways to target the business that we need that serves the community, grows margin and shareholder value. Q. (Sheryl Skolnick) Okay. So the easy thing is that over the next five to ten years, the number of commercial managed care heads is just going to decline, period, end of sentence; so you’re fighting an onslaught of the aging baby booms that we maybe haven’t thought about. Is that a simple way of saying it? A. (Dr. Newman) I think it’s true. Now remember there’s one other factor – Q. (Sheryl Skolnick) Yes. A. (Dr. Newman) And that is the issue of market share. And so we have evidence in some of our markets, as we have worked aggressively to expand our medical staff – anecdotal, not aggregated yet – that we’re growing market share by ZIP code, so that even in a falling tide, if we are able to expand market share, we keep up or grow our commercial managed care business. And the same is true in the Medicare Advantage plan. We’ve seen dramatic growth of our market share in that area in South Florida. It’s quite evident, as we look at the payer mix by region, those numbers which we don’t share with you, we can see where those shifts are taking place over time.
  • Tenet 2008 Investor Day Page 28 Q. Thanks. It’s Darren Lehrich from Deutsche Bank. Two questions for you. The first relates to a chart you put up, Dr. Newman, about the length of time, about 18 months in terms of the productivity of the physicians. And there wasn’t a scale on that chart, so I wanted to revisit that a little bit. If you could just give us a sense for the productivity of the doctors you’ve lost and the ones you’ve gained and give us a sense for how quickly we should see that result. I think you referenced more of a shorter-term negative impact; maybe if we can go back to that chart and you can talk about the scale and the numbers on there and answer that question. And then the second one is for Lloyd’s team, and I’m curious just to get your thoughts on the physician detailing in the context of the fact that there are lots and lots of detailers in the market – Home Health, you’ve got Hospice, you’ve got MedTech and pharma – and how effective you are in getting in the door and what you do to really get in the door. So if you could just give us a sense for that, please. Thanks. A. (Dr. Newman) Let me deal with the scale first, on the S-curve, and turn it over to Lloyd and the team to answer your second question based on their recent experience. We purposely left the scale off of that S-curve graph, and we did it for a very good reason. One is that we have very early numbers for that scale, and we have some numbers for Q407, we have some numbers for Q108 in terms of the productivity of that virtual 1,086 doctors that are the net of what was added versus that which was subtracted. I think it would be irresponsible for us to show you those numbers, because that would suggest to you that you should put those in your models and then estimate what our volumes are going to do over time. It is very early, and we’ve not validated those numbers yet. But I can tell you that the trend between the fourth quarter of ’07 and the first quarter of ’08 is significantly in the upward direction, just as we would intuitively expect, of doctors that have come on staff and begun to meet their referral sources and get more comfortable using the inpatient and outpatient facilities. Over time, as we get more quarters under our belt, and we feel comfortable with the validation of what that scale should be on the S-curve, we’d be happy to share that with you. But right now I don’t think it would be responsible on our part to do that. But you should feel good that today the hypothesis is proving accurate, and those people are increasing their business. Let me turn it over to Lloyd to answer the question of detailing. All right. I think John wanted to say something. A. (Mr. Landino) Yeah, let me answer that for you. We’re very cognizant of the fact that physicians are very busy, there’s a lot of clutter in their office, and that clutter is detail people – we like to call them vendors. We make a very distinct differentiation that we are not a vendor; we are there as an extension of the hospital, often marketing ourselves as an outreach arm of
  • Tenet 2008 Investor Day Page 29 the CEO, directly to make contact with that physician around three significant reasons: servicing their business, supporting their business, and helping to build and grow their business. It’s not what’s in it for our hospital but what’s in it for that physician, and how we can help and service them. So in that regard, we don’t compete with those detail people that come in with lunches and trips and coffee cups and all kind of gadgets that they hand out. We come out with the very simple, basic facts; that we have service lines that they feed into, that we can help them grow, we have core measures at our hospitals that are significantly better than our competitors. And so we do that right away and create that separation as a detail person and a vendor, and more as a collaborator and partner with them in growing their businesses. A. (Dr. Newman) Next question. Q. Hi. Rob Hawkins from Stifel Nicolaus. I want to understand the reach and the efficiency of the marketing program and its maturity a little bit better. I’m kind of using your Ms. Ramirez and Dr. Cogan examples, and a couple things kind of struck me as a little bit strange. You know, the call center directed her to a hospital 90 miles away from where she lived, even though you’ve got five hospitals nearby. The direct marketing campaign is targeting three counties away. You’re targeting a doctor that’s 70 miles away; you’ve got nearer hospitals. Is this only happening at a few hospitals, or have you started rolling this out? You’ve got like – it shows you have 50 marketing people you’ve hired. It looks like you’ve got about a person per hospital. I’m just trying to understand kind of where you are within the marketing rollout right now. A. (Ms. Brainerd) I’ll be glad to answer that. First of all, note that it was an archetypal hospital-physician setting. So in our story, if you’ll bear with us, that patient lived in the primary service area of that hospital, and so did the doctor. Although you saw some logos from a hospital in Palm Beach County, and a Miami phonebook, please know that was just for the purposes of illustrating a story. Every hospital in Tenet, all 55, works with the Tenet Call Center, and they do it in two ways. Sometimes it’s the local hospital’s marketing initiative. That hospital in our example that put a physician guest lecture, community lecture in the paper, that would have been a piece of work generated from that hospital to the call center, which is based in St. Petersburg, Florida, but it’s answered as the hospital’s name, and to that patient, they don’t know where it is; it’s very local in feel. Other marketing efforts that we’re doing from headquarters are things like those screenings, and all 55 hospitals have also participated in those screenings of one varying sort of another. And in that case, we manage the program from
  • Tenet 2008 Investor Day Page 30 headquarters for them and assist them with everything from the physician contracting so they can reimburse the physician. In the case of the EKG screening, we had to actually contract with physicians to participate in that. We hold administrative calls so they’re up to speed on everything from how to place the signage to how many phlebotomists you need to have available so you can move those patients through correctly. But the call center touch is really all of our patients and all of our marketing efforts in many different ways in a rather customized fashion. Q. (Indiscernible – no microphone). A. It’s based on the particular screening. EKG, the $39 heart health assessment was our first one, and that did roll out about 12 months ago. And I believe about 50 of the 55 hospitals have participated in that one. And they go through in waves. It takes six to nine months to start seeing that patient in the hospital for work, so some of them choose to go 12 months ago, and then six months later, they want to go back in again with that screening. So some have actually participated in three screenings – two cardiacs and one PVD; others went in for one cardiac screening. Based on the capacity of their physicians, some hospitals have a smaller medical staff of cardiologists, and once every nine months might suit their needs versus one who wants to be more active. Q. Hi. Kemp Dolliver with Cowen. Two questions; first on the attrition statistics you showed in the slide, how does that compare to say a year ago, or other periods? Is that the steady rate of attrition, or is that an improvement? A. (Dr. Newman) We think it may have slightly improved in 2007, post- Global settlement. We talked earlier about hedging the bets and whether they would drop privileges or not; so we think attrition is down. I should add a little note about attrition here and there. Those physicians, that pool has significant fluxes in it. For example, we changed out six of our emergency medicine staff groups in our Florida hospitals in 2007, all over a period of about 90 days. So you had a number of physicians coming in, and a number of physicians coming out, which is a net to zero, in terms of the 1,086. But clearly, as we change hospital base groups, as we change a hospitalist group, which has now become prevalent in about 35 of our hospitals across the country, these are a large number of physicians that might come and go over a relatively short period of time. Q. (Kemp Dolliver) Okay. And the second question relates to the business development activities overall. A lot of these things, I see elsewhere; you know, advertisements, notices to patients, or reminders of appointments. To what extent are the activities you’re engaged in now actually unique for the industry, and how much of what you’re doing is just, quote,
  • Tenet 2008 Investor Day Page 31 “getting back in the game,” since you haven’t been able to spend a lot of money here before? A. (Dr. Newman) Let me just give you sort of a value judgment on that. It’s difficult to answer that objectively, but I’d say half of it is getting back in the game, and as usual, and the other half is innovative. Our database marketing approach is not done very frequently in the hospital industry. Certainly, many consumer manufacturing companies use database marketing, but its introduction into hospital management and operation is relatively unique. And we have an amazing database of patients. How many patients in the database now? A. (Ms. Brainerd) Hundreds of thousands. A. (Dr. Newman) Yeah. I mean, when you think we admit 590,000 patients a year, and doing an average of 4.2 million outpatient visits a year, the database that we’ve developed over the last few years, and which we continue to revise, refine, segment, and then target based on age and gender, it’s truly a powerful tool to get to the consumer. That channel, along with dealing with the physician channel in a clearly industry-unique fashion of matching the physicians in the high-performance managed care networks with the existing medical staffs to create high-yield targets for our PRP representatives to go after in their own primary service areas is an innovative and, to my knowledge, not duplicated technique and initiative in the industry. So about half and half, Kemp. Half is what you see elsewhere, and half I would consider to be innovative. And the integration is innovative, because obviously, most hospitals and health systems don’t have their own call center, and they farm that out, as we are doing work for 22 health systems across the country. So I think that it’s fair to say it’s a pretty good balance between those two. A. (Mr. Landino) Hey, Steve, can I add one comment to that? A. (Dr. Newman) Go ahead. A. (Mr. Landino) All right. One of the things to point out that we are doing very unique from everyone else is on this training slide that Lloyd put up. Most sales and marketing organizations go through the type of core upfront training that we did with our staffs last year. But the movement into 2008, 2009, 2010 is now compressing this training is a whole hospital initiative – and this is unique in the industry – where we’re bringing our CNOs through training, our staff nurses through training, clinical service line managers, nonclinical service operations managers – all understanding the importance of the physician, as a customer when they’re inside our facilities, being able to have readily available to them the unique things about their clinical service lines that are important to that physician to reach out and touch to them. So this training is going into our
  • Tenet 2008 Investor Day Page 32 entire hospitals, not just the one or two people that are out in our markets calling directly on the physician offices. A. (Dr. Newman) We can take one more question, and then Tom wants us to have the break. Q. Thanks so much. Shelley Gnall from Goldman Sachs. Just looking for some clarification on the commercial managed care outlook. The aging of the population and the growth in Medicare Advantage notwithstanding, would you expect in 18 to 24 months, as those newly recruited physicians – given the profile of the docs that you are recruiting – do you expect the commercial managed care business to be up and growing? A. (Dr. Newman) I think that we’ve not given a specific outlook for the segment of our business other than we said that our Medicare Advantage plan was growing very rapidly in a positive way. It would follow that if we are successful in targeting those physicians that have preferentially large books of commercial business, and we win their business, that over the next year, you should see at least the loss of managed care quarter-over-quarter gets smaller, and then sometime in the future, turn positive. But that is the goal, that’s what we’re on, like a laser. And we think we’re attacking it from a number of different angles that will aggregate to being successful over time. Dr. Newman: I want to thank you for participation in the Q&A session. And should we start the break now? Mr. Rice: We’re going to take a break now. We’ll be back at 10:35. Dr. Newman: Thank you. (Break) Tom Rice You can all take your seats, please. I can hear the chimes going out in the hallway so we’ll wait just a moment or two for people to re-enter the room and get properly settled. We’re going to have the regional reviews at this point. Let me just cover – while people are concluding their conversations and grabbing their seats – let me just make a couple of logistical points. I was asked during the break about the slides. The slides will be available in their entirety at the conclusion of the day. In fact, if you were in attendance today, you will receive an e-mail from us as soon as the event is concluded that will contain a link. Just click on that link; you’ll go right to where all the slides are on the Web.
  • Tenet 2008 Investor Day Page 33 The other thing I wanted to announce is that lunch, which will be in the room right behind us here. We will have identifiers on each of the tables so if there’s anyone that is speaking this morning that you want to spend more time with, look for their name on the little tag on their table and you’ll get to spend an hour with them that way. I see a few more people coming in but why don’t we get started. Steve Newman will take you through the regional reviews. Dr. Steve Newman Welcome back. I hope everyone had a chance to answer their voice mails, to do two or three BlackBerry e-mails in response to questions you were asked, and got to talk to our group during the break. Certainly more of that to come during the hour lunch break that will come after our regional presentation and the Q&A session. So unlike last year where we featured individual hospitals, like Houston Northwest or Los Alamitos Medical Center, we decided this year once again to let our regional leaders share with you their unique perspectives; specifically, how they’re bringing to life the initiatives that Trevor and I spoke about this morning in their specific regions in their hospitals. We have a great wealth of talent in terms of our regional leadership. As I was thinking about it this morning on the way to the hotel, we have over a hundred years of multi-facility management experience within the ranks of our regional leadership today. A few years ago, we had 11 regions. Today we have four regions and the Philadelphia market. We’ve trimmed the overhead significantly and we’ve focused these leaders on delivering value from a service perspective as well as holding our hospitals accountable for hitting all their performance metrics whether they’re cost metrics, growth metrics, or quality metrics. So it’s my pleasure to introduce each of these in order of presentation. So I would ask you to tighten your safety belt because we’re going to do a transcontinental flight from the West Coast all the way to the East Coast and we’re going to start with our California region. Our California region is led by Jeff Flocken, our Senior Vice President. Jeff took over his position about 16 months ago and has over 25 years of multi-facility management experience in California. He’s recognized statewide as an expert in healthcare delivery. He serves as an executive committee member of the California Hospital Association and he’s really brought great energy and enthusiasm to our California operations. So I’d like to ask Jeff to come up now and share his unique perspective on what we have in California. Jeff.
  • Tenet 2008 Investor Day Page 34 CALIFORNIA REGIONAL REVIEW Jeff Flocken Senior Vice President, California Region Well, thank you and good morning. Steve shared with you his four prescriptions for success earlier this morning and I’d like to spend my time with you talking about how we’re executing on those strategies and tactics within the California region. And let me introduce you to the California region again by starting with our patient, Mrs. Ramirez. Now, Mrs. Ramirez is actually a California native and she finds herself in need of medical care and she could likely be treated in any of our 13 facilities today within California. But initially, you might think of her as potentially being one of those 18 percent of the uninsured that exists within California – or 18 percent of the population. But in our seven distinct markets we serve, we actually have better demographics than the state as the whole. Our markets are projected to grow through population between 4 and 22 percent over the next five years. And our payer mix is more favorable overall in our markets than the state with ten percent less uninsured, 20 percent fewer Medi-Cal beneficiaries in our market, and ten percent more commercially insured within the markets that we serve. In addition to the markets that we serve, seven out of those markets – or 11 of the 13 hospitals – have median household incomes of above statewide average of $56,000 per year. And in fact in many of our service areas with market shares that range from Orange County of 13.5 percent, San Luis Obispo County where we have 51 percent market share, the Modesto/Manteca area where our market share is 31 percent and the Coachella Valley where our market share is 55 percent, chances are already that Mrs. Ramirez could be one of the patients that we see or have seen in our hospitals before. And our market demographics are in part also reflected in our bad debt and charity care performance for the organization for our region. Our region’s bad debt and charity care performance is better than the company wide statistics for 2007 and 2008. This trend is continuing for us in the first quarter to Q108. Now, you’ve all heard Trevor speak about – and Steve speak – about our targeted growth initiative. So let’s come back to Mrs. Ramirez and Mrs. Ramirez happens to be a patient who lives in Los Alamitos, California, which is an upscale area just south of Long Beach. Two years ago, Mrs. Ramirez might have received her care or selected a hospital in the Long Beach area for her care even though it isn’t as convenient as our hospital or as close to her home in Los Alamitos. Now, a year ago, you heard Michelle Finney, who was our CEO talk about applying targeted growth for the development of the cancer service line, part of which included a $10 million investment in a freestanding cancer center enhancement of those services at the Los Alamitos campus. Well, let’s roll forward one year to our patient, Mrs. Ramirez.
  • Tenet 2008 Investor Day Page 35 She’s come to our hospital as a result of a referral from the Leisure World Clinic, which Los Alamitos Medical Center staffs, markets, and manages. Her first stop at Los Alamitos is the Total Care Imaging Center, which is a freestanding imaging center located adjacent to the new freestanding cancer center. After having a diagnostic mammography with the new digital mammography equipment at Total Care, our radiologist refers her to one of newly recruited physicians, a female-trained breast surgeon. This breast surgeon, who we’ll call Dr. Carol Cogan, is one of the approximately 400 physicians that we’ve identified for recruitment or relocation over the next three years through our manpower planning processes. Now, Mrs. Ramirez could be scheduled for her surgery at the Reagan Street Surgery Center, which is located across the street from the hospital. The Reagan Street Surgery Center, which was recently acquired several months ago, is a joint venture with 30-plus surgeons in which Los Alamitos owns a 51 percent market share. Following her successful surgery, Mrs. Ramirez could be referred to the Total Care Radiation Therapy Department where Dr. Javier Ray, one of our more than 83 physicians that California hospitals have redirected through out Physician Relations Programs through the first quarter. Our successful Physician Relations Programs have been responsible for over 1,800 physician contacts in the first quarter and in addition to these 83 redirections, our reps have successfully executed approximately 20 new physician relocation agreements based on community needs and that brings us to within 50 percent of our goal for relocation of physicians in our service area. So let’s talk about what does that mean for Los Alamitos? What are the results then? Well, our oncology treatments grew 9.2 percent or 1,200 visits. Our radiation oncology procedures have increased 563, or 7 percent growth, and our breast procedures increased 731, or 6.1 percent growth. The oncology service and the application of TGI is just really one example of what we’ve done in the region based on targeted growth and how it’s driven our capital investments and results. We’ve implemented other things such as the investment of three new catheterization laboratories at JFK, Lakewood, and Desert, our Outpatient Pavilion and Diagnostic Center, which is going in at Placentia Linda, which is scheduled to open the first quarter of ’09, our Neonatal Intensive Care Unit at JFK Medical Center in the desert, our new Joint Venture Ambulatory Surgery Center out in the desert – the Donors Surgery Center – and our Cyber Knife Joint Venture, which we’ve done at Creighton University Medical Center, which also happens to be in the California region. Now, what you may not be aware of is that Mrs. Ramirez also has a niece who recently graduated from nursing school and was hired by Desert Regional Medical Center in Palm Springs. She represents our core strategy around people. And our commitment to people efforts at Desert and elsewhere have led to reduced turnover and higher employee satisfaction and higher physician satisfaction. Aggressively addressing recruitment and retention helps attract the best physician and also makes good business sense. Each percentage point reduction in turnover is worth $3 million to our region through savings in contract labor and overtime costs. It costs us about $75,000 to replace a nurse who
  • Tenet 2008 Investor Day Page 36 resigns and California has over 5,000 nurses. Within California, we’ve had the best turnover rates but we’ve been improving on those and we’ve reduced our turnover rates to a run rate from 20 percent to 18 percent this year. We’ve done that through the programs that Dr. Newman talked about earlier – our Versant Residency Program, our on-boarding programs, our leadership development, and our leadership training program. And in addition to that, we’ve received over $3 million in grants from the state to expand our manpower training within nursing. And what you might also not realize is that on quality, nursing care and nursing measures actually drive two-thirds of our quality measures and our core measures for Medicare and our infection control measures and our CMS scores within the California region are currently as good, or better than our competitor systems within our region. In addition, our quality measure, as measured by our 59 Center of Excellence Award in Designations, has also driven business to us. For example, our bariatric certifications for our Bariatric Surgery Centers allow us to treat Blue Cross patients that would otherwise not be covered for these services at our hospitals. And our quality scores have also allowed us to position ourselves for paid-for-performance contracts including a pilot program that we’ve implemented up in Modesto with the California Healthcare Coalition, which is a coalition of 35 self-insured employers and union trust funds. In Modesto, our pilot program with Gallo and the United Student Commercial Workers’ Union affords us a four percent bonus based on achieving improvement in selective quality metrics over the course of the contract. We also participate in an organization called Chart, which is a joint collaborative of hospitals, physicians, insurance companies, nurses, and consumers that sponsors a Web site called CalHospitalCompare.org, which is a comprehensive, consumer-oriented online report card that can provide just about anything you want to know about quality in California hospitals. And the purpose behind this is to have uniform reporting so that we’re not doing reporting and redundant reporting for many different organizations. And we’re one of 200 hospitals that sponsors and participates in that. Now, while we’ve been improving our quality, we’ve been investing in our people, and we’ve been growing our business, we’ve also remained focused on cost management as well and our efforts have yielded positive results in the region. Our labor costs, even with union contracts, has risen only 3.1 percent quarter-over-quarter from prior year and our paid FTEs have been reduced by two percent. Our supply costs have increased 1.3 percent over the prior year and while our other controllable expenses has grown 4.6 percent, this has been primarily due to two factors; one, an increasing cost in securing emergency room coverage by physicians for some of our hospitals and the legal and consulting fees associated with the USB litigation. Revenue management has also been another key component of our success. And Clint Hailey will talk to you this afternoon specifically about the successes in managed care contracting, which we participated in within our region. But one of the big benefits has been our new four-year contract with Blue Cross and if you look at our year-over-year numbers within the region, our net managed care revenue was up 7 percent over the same
  • Tenet 2008 Investor Day Page 37 quarter last year and we expect that to be even higher as we feel the full implementation of those contracts take effect with the new managed care contracting. Now, even with our successes, we’re positioned well and we believe that we’re in robust markets with good growth indicators and above-average demographics; we nevertheless face a number of challenges going forward. First is our ability to grow our outpatient volume. But I think we’ve developed a good strategy as exhibited by what we’ve achieved at a hospital like Los Alamitos and that has been replicated at other sites and facilities within our region. We’re doing this through acquisitions, through joint ventures, and in some cases, just plain development of new service and new service sites where we think that’s warranted in the market. We’ve also seen a growth in our Medicare Advantage Risk Plans and HMO coverage. We’ve had year-over-year growth of about 16 percent in the Medicare Advantage Plans, but we also think that’s an opportunity for us. Coupled with our Physicians Relations Program and our efforts as physician redirection, we also have the risk management infrastructure that exists within our region to capitalize on this. And in addition, we’ve also done joint marketing programs with several of our medical groups for Medicare Advantage members, which we ultimately believe will also grow our market share. A key to our success going forward is also the execution of our manpower plan. We need to accelerate the physician recruitment and redirection. Through May, we’ve added over seven additional employees whose sole focus within the region is focusing on our manpower relocation and redirection efforts in addition to what we already had in the region before that. And finally, our staff recruitment and retention. Our on-boarding improvement, our leadership development, and clinical advancement programs not only will help us to achieve a workforce that will be comparable to others within the region and to be better than others within the region will also be a cost-benefit to us as well. Finally, if I could leave you with concluding thoughts is that we are focused and have a prescription for success. We’re focused on our quality, we have favorable demographics and growth in our markets, we’re making progress on recruitment and retention, we’re accelerating our physician recruitment and redirection, an expansion of our outpatient footprint, all of which will lead to margin growth ultimately. So that’s my quick trip through the California market and I’ll turn the podium back over to Dr. Newman. Dr. Steve Newman Well, thank you very much, Jeff, for that quick review through those important assets in California. I think we heard a couple of things that are very insightful, especially for those new to our audience. One is that the bad debt in California where we always hear the discussion of uninsured and what the major problem is. In our particular facilities
  • Tenet 2008 Investor Day Page 38 based on their geographic footprint, are disproportionately low and in fact lower than the overall corporate average. Second thing that I thought that was very interesting was the point you made about direct contracting and the issue in Modesto where the Gallo Wine Company and the United Commercial Food Workers are contracted directly with the hospital, with the PPA, because they were not happy with their commercial managed care, owner-sponsored plan. Third thing, was your own unique approach to allocating capital related to the targeted growth initiative where that market opportunity and cancer services at Los Alamitos had been identified and you specifically dedicated a significant amount of your regional capital to grow the cancer services at that capturing that population and actually redirecting those patients that had been out migrating previously to another competitor that offered surgery care services. So I think a lot in that presentation. I want to thank, Jeff, for the review of California. And, now, as we prepare to take off in our airplane, we fly to the Central States Region and to Texas. Our Central States Region consists of hospitals in Missouri, Tennessee, and primarily Texas. It’s led by Bob Smith who has over 30 years in managing hospitals, multi-facility management. Bob serves on the Executive Committee of the Texas Hospital Association and is known as an expert in hospital management in this part of the country. So let me welcome Bob up here to take a run through the Central Region. Bob. CENTRAL REGIONAL REVIEW Robert L. Smith Senior Vice President, Central Region Thank you, Steve. Appreciate it. Thank you very much. Good morning, everyone. Usually, by the way, Steve said earlier, “Hundred years experience.” He usually looks at me with 100 and 15 or 20 for the others. So this is, as we said yesterday, this is what 30 years of hospital management does to you. So don’t do it lightly; don’t try this at home, right. Don’t try this at home. Not for the faint of heart. I want to talk about several key messages this morning and these go to our TGIs, our Targeted Growth Initiatives. And we started that in 2005 in the Central Region, or what used to be the Texas Region, and talked a little bit about our markets, our physician employment, expanding our outpatient footprint, and then also increasing our Case Mix Intensity, CMI, or the severity of patients that we serve. Now, relative to the markets, in Missouri and Tennessee, these are Certificate of Need states. They are lower growth states and for us, it’s basically St. Louis and Memphis. We have suburban facilities in those markets and we have urban facilities in those markets
  • Tenet 2008 Investor Day Page 39 and so they’re lower growth states without the profile you have in Texas but we do have Certificate of Need protection here. And so Certificate of Need creates a barrier of entry and, to a degree, franchise protection on the inpatient side and then a little bit on the outpatient side. It depends on what you’re asking for in terms of the type of service and the dollar level. So we do have some franchise protection here and a barrier of entry to both of these markets. Relative to Texas, we do not have Certificate of Need in Texas. It’s a much higher growth profile that we hear; Texas is expecting to grow 17 percent over the next five years with a national average of about 4.6. So we’re three times the national average in terms of growth rate, which makes us a very attractive state for us to do business in. And, by the way, talking about Dr. Cogan, in 2003, the legislature passed tort reform in Texas and so it creates an opportunity for lower malpractice expense, lower exposure. And since that time, our applications for licensure for physicians have gone up double what they used to be. We used to average in the state about 2,000 applications a year, now we’re up to 4,000, 4,500 applications a year. So it’s helping us recruit and the legislature did a good job of bringing that on line; very attractive to the Dr. Cogans of the world. You can see from this slide that our micro-markets, or our primary service areas, are growing even more rapidly than the major urban areas that we do business in. And so it further makes those markets very attractive to us. If you’re in and Mrs. Ramirez is in and her family and Dr. Cogan are in the DFW markets, which we’re in today, it is expected to be the third largest metro area in the United States by 2030, so tremendous growth here. When you look at the two cities together, it’s going to be over 6.5 million people or if they’re in Houston today, Houston is the fourth largest metro area existing today, so good markets for us. Further, in El Paso. Dr. Cogan likes to practice in El Paso and is probably attracted to one of our three hospitals there – first, our new one, which opened just a few weeks ago – but the market in general is growing rapidly; twice the pace that we see in the state and on the east side where our new hospital is because of the BRAC, the base realignment. Ft. Bliss is in El Paso and so the BRAC base realignment is expected to bring 65,000 troops and their families into this market over the next five years and then, of course, all of the spin- off business that goes with that; all of the different businesses and the population that will come in to support that. So these are very attractive markets for us. Again, we started in 2005 with our Targeted Growth Initiatives and physician employment, outpatient services, and growing intensity all create market relevance and margin drive. Now, Mrs. Ramirez. Once Mrs. Ramirez determines that she has a problem and maybe does not have a physician; she talks to friends, family, neighbors, and goes to the Internet – and you heard about this earlier. Within our region, if she goes to the Internet and goes to HealthGrades, we have 1,300 physicians participating in our region in HealthGrades with 1,100 physicians who have what are called advance reports – you saw a copy of an advance report this morning – and so once she goes there, she’ll be one of over three million people that are searching for a physician within our region, one of 780,000 who open a physician report. I think Lloyd showed you earlier that there’s four
  • Tenet 2008 Investor Day Page 40 million of those openings within the overall company annually, 780,000 in our region; and asking for an appointment would be over 208,000 people. And so this is driving a lot of business into us and clearly, once someone has a lot more information about a physician, they are more apt to make an appointment and go see that doctor. So HealthGrades is working and working well for us. And so once Mrs. Ramirez gets to a doctor, maybe not by HealthGrades, but possibly by HealthGrades, she may end up in one of our employee-physician practices. This is a picture of one of our practices in the Houston market. This is where we started our physician-employment reentry into this side of the business and we currently have 20 physicians in six markets. Right now, we have 13 sites with those 20 physicians and we expect to grow to about 40 physicians and 23 sites over the next couple of years. Now, this is not going to be our primary source of physician development. If you look at our region, employed positions are only about one percent of what we have in terms of physician growth. So the primary physician growth, again, will come from relocation and redirection, and just basically recruitment means that we have. And with the growing shortage that’s expected of adult primary care providers of 35,000 to 40,000 by 2025, this is a significant means for us to begin to address that shortage and have the growth opportunity within our region. And what you find is normally graduating residents today and primary care specialists are seeking employment opportunities for their career entry. Many of them don’t stay there but they seek that for their career entry because it’s pretty intimidating going out and starting and opening up a private practice. So it is helping us and we’re beginning to do this now in Dallas. We’ve done it in Houston, as I said. We’re also going into El Paso with it and we have an employed position in the Memphis market also. Now, taking a look at the utilization patterns. Once Mrs. Ramirez gets to Dr. Cogan and he determines that he may have to utilize some inpatient services, we’ve looked at it that both employed and non-employed positions and within the Central Region, what we see is an average of 70 to 120 admissions per year from our primary care physicians. So an internist or family practitioner normally drives about 70 to 120 admission a year. It may not be them directly; they may be sending that to a specialist, they may be sending that to a hospitalist, but on average, irrespective of practice style or practice and methodology, we see this type of volume drive. Now, once Mrs. Ramirez gets to Dr. Cogan, he determines that she needs services. If it’s not a hospital, it’s more than likely one of our outpatient settings or either hospital based or non-hospital based. I’ll take you through a brief scenario of the Lake Pointe Medical Center Diagnostic Imaging Center that we opened two years ago. In fact, when we talked about it at this meeting two years ago, it had only been opened a month and we are replicating this and doing it in many other markets. We are opening these imaging centers and other outpatient businesses mostly in non- Tenet owned MOBs, medical office buildings, where there are aggregations of physicians. This is where the Diagnostic Imaging Center is in Lake Pointe. Lake Pointe is
  • Tenet 2008 Investor Day Page 41 a suburb of Dallas up on the northeast side. This is an 85,000 square foot medical office building with 30 physicians in it and so if Dr. Cogan’s in this building, he’s one of 53 physicians that sends an average of 2,500 procedures a year to the Lake Pointe Imaging Center. So it’s beginning to get early maturity in that. And what we see are higher margin business on the outpatient side so overall these types of developments are lifting the margin for the region and obviously for the company. Once Mrs. Ramirez gets to the Lake Pointe Imaging Center, she’ll find that we have a number of other outpatient services available away from the hospital. We’ve developed 11 sites over the last two years for imaging, sleep labs, urgent care centers, physical therapy, wound care, and so we’re broadening the base of entry points with the employed positions with the outpatient centers and improving our margin. Things like the Urgent Care Center are in the building for Lake Pointe; we also have our sleep lab there. And so once Mrs. Ramirez is there and sees all of those services available, she may begin to utilize other parts of the system. Now, Dr. Cogan, he likes this setting because it’s tied to our medical records and all of our electronics that we have in place in all of our hospitals and so he can receive interpretations on the PACS System and other reports and diagnostics electronically, whether that’s inpatient or outpatient. So these sites are all tied in to our system and then both will find ease of scheduling and Mrs. Ramirez may utilize online scheduling and online appointment or she may utilize our kiosk check-in and you’ll hear more about the kiosk check-in and online registration from other presentations today. This is a copy of the screen. When you walk in, you can do this very airline style. It eases the process and the patients like this quite a bit is what we’re finding. And again, all these services are driving for us higher margin, higher volume, and improving access points. Now, finally, if Dr. Cogan determines that Mrs. Ramirez does need inpatient services, he’ll find that we’ve intensified the service offering base throughout the region. We’ve increased our Case Mix Index, CMI, or the severity of patients as the indices for severity of patients, as you know, at eight of our 13 hospitals from ’06 to ’07, and that’s continuing into 2008. And you can see a nice push up there on both Medicare and non- Medicare. It goes back to the question about market relevance and managed care and managed care positioning. What we’ve found over the years is hospitals that have lower intensity don’t have as much market relevance. Hospitals with higher intensity, higher market relevance and so we’ve been working to improve the intensity over the last 30 months in our region as part of the TGI offering. So that includes things for Mrs. Ramirez and for Dr. Cogan, like our neonatal intensive care units that can care for her children and grandchildren, vascular programs, and we know she needs that, our neuro and stroke services, and we’re doing some of this on the tele-medicine basis to bring services available to hospitals that don’t have the proper component of physician. We’re using a lot of electronics and tele-medicine to drive these programs. Spine and orthopedic surgery, which some of you may want to see us after the meeting and sitting in these chairs all day, see if we can make you a quick referral to one of our markets. Our oncology programs and even ER trauma designations that help
  • Tenet 2008 Investor Day Page 42 Dr. Cogan practice at one of our facilities. So it’s improving market relevance for us and we’re also driving margin because assisted with case managers and assisted with utilization, electronic utilization processes that we have in our hospitals, we’ve also begun to address overall length of stay and so we’ve dropped our length of stay from ’06 to ’07. The early ’08 numbers are a little difficult because the first quarter is usually high- intensity patients, which often drive a little bit higher length of stay but overall on a Case Mix Adjusted Basis, what we’re seeing are the length of stays coming down on the Medicare side that’s translating also into the managed care side for us, which often has fixed reimbursement. And so the Medicare, as you can see from this slide, Medicare intensity going up, the length of stay going down, and what we see in our region is for every 100th of a point that we can raise Case Mix Index, it brings about $5.6 million worth of net revenue into the region. Now, that’s not EBITDA, that’s net revenue and we have the costs that goes along with serving that business. But the higher intensity drives better net revenue for us. So the dynamic here is very, very easy. Higher intensity, lower cost driven through lower length of stay improves our margin, increases market relevance, and gives us the longer term play overall. So in summary, our region has attractive markets, you know, we have some degree of franchise protection, and some Certificate of Need and/or we’re seeing high growth rates especially in the micro-markets that we’re in. We’re continuing our TGI focus that started for us in late ’05. I talked about some of it being implemented in ’06; there’s a gating process obviously that goes on. We’ve begun the physician employment side and let me underscore a question that came up earlier and maybe a response. We are not acquiring practices, we are employing physicians. Ten years ago or 15 years ago when we all got into this process, people were acquiring practices and employing doctors. We are not acquiring practices; we have a standard methodology to employ the physicians, a standard agreement, a standard compensation mechanism, and so we’re not buying practices, we are employing doctors. We’re expanding the access points through the outpatient profile, both at the hospital and away from the hospital, and then as I said previously, growing intensely that gives us market relevance and margin growth in our region. So, Steve, thank you very much. Turn it back over to you. Dr. Steve Newman Well, Bob, thank you very much for that insightful review of the Central Region. I think we heard a couple of really interesting facts in your presentation including that Certificate of Need protection for our hospitals in Missouri and Tennessee and how that creates barrier to entry and allows you to more methodically deploy your capital and add services in a more selective fashion.
  • Tenet 2008 Investor Day Page 43 I think the other points of the intersection of the growth of Case Mix Index with the Targeted Growth Initiative just reinforces the power of that in terms of the generation of revenue and the creation of what you termed Market Relevance, specifically again creating a barrier to entry or duplication in markets that are frequently very competitive. So I want to thank you for your presentation and let us fly toward the southern states region. Dr. Steve Newman Southern States Region is led by John Holland, our SVP, and John has many years of experience managing individual hospitals in this company all the way from California to Georgia, a couple of stops in between. He leads our most geographically diverse region – the Southern states – and we look forward to a great presentation from John. Come on up. SOUTHERN STATES REGIONAL REVIEW John Holland Senior Vice President, Central Region Thank you, Steve, and good morning. Today, I’m telling the story of Mr. Robert E. Lee Beauregard, a distant southern cousin of our archetypical patient, Mrs. Ramirez. Before doing that, I’d like to summarize what you’re going to learn about our hospitals. Our region consists of 12 facilities in the Carolinas, Georgia, Alabama, and Louisiana. For obvious reasons, we don’t count Florida as a southern state. First, our markets are attracted demographically, which means high rates of population growth and commercially insured patients. Secondly, our markets vary in size and are relatively spread out, therefore, our services reflect the diversity of the market that we serve as do our strategies and tactics. Finally, trends seen in other areas of the country, such as freestanding, outpatient centers, managed government payers, and specialty hospitals have only recently begun to impact our operation. We have Certificate of Need legislation in four of our five states. Today, you will hear about how our region’s own prescription for success affects the experience of our patients. Take Mrs. Ramirez and Mr. Beauregard and physicians like Dr. Cogan have in our hospitals. First, we form a foundation of trust by improving clinical outcomes and assuring that patients are safe. We empathize with our patients and physicians by listening to their needs and delivering world-class service to them. We energize our efforts by recruiting and returning great physicians and employees. We create value by improving our cost metrics. And finally, we create alignment of resources
  • Tenet 2008 Investor Day Page 44 by growing volumes through the Targeted Growth Initiative. Our efforts create a virtuous cycle that attracts both physicians and patients. Now, many patients’ first encounters with hospitals are through emergency rooms. Mr. Beauregard’s story begins when he is involved in a motor vehicle accident and is taken to Atlanta Medical Center in downtown Atlanta. If you recall, Mrs. Ramirez had an excellent experience with one of our hospitals in Florida and told all of her relatives and friends about it, so Mr. Beauregard asked to be taken there. Atlanta Medical Center happens to be one of our two trauma centers in Georgia so the ambulance driver or paramedic willingly meets his request. Decision on where to take Mr. Beauregard is based on both protocol and the paramedic’s knowledge and experience with the capabilities of each hospital. So quality, convenience, the nursing and physicians’ staff, and the equipment available all play a role. The paramedic was also probably aware of the posters we put up in our hospitals comparing our quality results to other facilities. In the Southern states, we utilize Chief Medical Officers, Directors of Clinical Quality, process-oriented clinical close calls, and balanced score card incentives to improve our reportable clinical data and then we share it with our customers. The result is performance that exceeds the national averages; an outstanding performance by a number of our hospitals. In fact, we have a facility that ranked number one in Georgia and was only one of 27 hospitals nationally to receive designation status for all three American Heart Association programs. The paramedic may also be aware of our Centers of Excellence Designations. We have 45 designations in the Southern States Region. Service Results demonstrate that our most important customers, patients and physicians, are extremely satisfied with their experiences at our hospitals. In fact, the Southern states led Tenet in 2007 in service metrics. Hardwiring proven patient satisfaction techniques and making sure that we follow up with our physicians, make a difference. Great experiences in our hospitals are key to developing repeat and new business, like Mr. Beauregard. From the standpoint of emergency care, satisfaction with our emergency rooms is excellent and improving. We utilize electronic paperless systems like MEDHOST, you see here in our hospitals, to track patients, take orders and report results. And we make sure that our ER physicians are incented to see patients quickly and provide high-quality service. Odds are that Mr. Beauregard was very pleased with his care at Atlanta Medical Center. Our people are a key element in driving successful results. We’ve reduced employee turnover through training our supervisors, utilizing new grad programs, piloting new initiatives to select the right people, and developing our hospital leaders. To put it very simply, the hospitals with the best employees and physicians tend to win.
  • Tenet 2008 Investor Day Page 45 Speaking of physicians, attracting both new and existing ones is critical. The foundation of clinical quality, outstanding service, and the right equipment is essential, but it doesn’t stop there. We get the word out through our PRP program to redirect existing physicians like Dr. Cogan. We work with our recruiters to bring new ones to our community. We provide employment opportunities. We develop hospitalist programs for primary care physicians who want to stay in their outpatient practices. We provide joint venture opportunities for surgeons who wish to invest in freestanding surgery centers and medical office buildings. We provide call arrangements for physicians who are covering our emergency departments. In fact, we’re piloting an innovative deferred comp plan for three of our hospitals. Assuring that we’re staffed appropriately is important for delivering value to patients like Mr. Beauregard as well as our shareholders. Monthly labor analyses, “Deep Dive” operations reviews, and internal consulting engagements that focus on efficiency, best practices, and workflow have been the prescription for the stuff in this area. The result has been the savings of more than $12 million over the past four months. Managing bad debt expense is also important. Thankfully in our region, bad debt has been less of an issue than in other areas of the country. Now, back to Mr. Beauregard, who had been driving from his home outside Hilton Head, South Carolina, to attend a convention in Atlanta when he had his accident. Hilton Head is a market that has been targeted by a nationally known active adult retirement community, provider named Del Webb’s Sun City. And that provider has focused on a number of very attractive markets in the southeast for development. In fact, if you overlay their existing and perspective development, it appears that they’re attempting to locate near our hospitals. While I’m not sure that’s their intention, it does demonstrate that we’re well-positioned for future growth in this important demographic. Our facilities fluctuate in size and complexity ranging from 25 beds at Sylvan Grove outside Atlanta to 586 beds at Brookwood Medical Center in Birmingham. We view our region as six distinct markets and ten submarkets. It’s not surprising that Mr. Beauregard chose to live in coastal South Carolina, but he and his family could have chosen to locate in a number of other markets that are growing at compound annual rates that are more than double the national average. Mr. Beauregard happens to be insured by a commercial managed care payer, which is not unusual as our hospitals demonstrate relatively high percentages of commercial managed care business with two of our facilities around 50 percent and five over 25 percent; the region averages 30 percent. While hospitals are our primary asset, Mr. Beauregard would be pleased to know that he could take advantage of a number of outpatient settings as well. In fact, we have nine freestanding ambulatory surgery centers – five of them ventured with physicians – eight freestanding diagnostic centers – we’re adding one at Piedmont Medical Center as well – and eight urgent care centers in our region. In the Greater Hilton Head area alone, we have two hospitals, surgery and diagnostic centers, and an urgent care facility.
  • Tenet 2008 Investor Day Page 46 All of our efforts come together through the Targeted Growth Initiative. We deploy humans, physicians, and capital resources to develop targeted services for each of our hospitals. Examples of the results of our initiatives are a Women’s Center at Spalding Regional, a proposed freestanding emergency center southeast of Birmingham, a proposed Women’s and Amenities expansion at Brookwood Medical Center, a Neuro Intensive Care Program at Atlanta Medical Center, an Intensive Care and Surgery Tower at North Fulton, an expanded replacement hospital for East Cooper and Charleston, which will focus on women’s and spine services, and, of course, our latest acquisition, Coastal Carolina Hospital in Hardeeville, South Carolina, just outside of Hilton Head where Mr. Beauregard can receive his follow-up rehab care when he gets home. This story truly has a happy ending from his perspective. Targeted growth, improving clinical outcomes, recruiting physicians, managing our labor, and dealing creatively with the ER on-call issue are all prescriptions for dealing with our biggest challenges in the Southern states, namely softening demand and pricing for inpatient services, strong not-for-profit competition, and rising costs. Our results so far, which I’ve already shared with you, are very encouraging and bode well for the future. So we’ve come full circle and our virtuous cycle is complete. We’ve built a foundation of quality and service to which we’ve added a dose of great people and good, old-fashioned cost management and pulled it all together through the Targeted Growth Initiative. I’m really excited about our future prospects. Thank you for your time today. Dr. Newman. Dr. Steve Newman Well, thank you, John. I think we certainly got some great insight about the Southern States Region in addition to the fact that the Del Webb Corporation is smart enough to use the location of our hospitals in part of their business intelligence in terms of developing their retirement communities. We were there first, right. But we also learned some other things that I think are really important, specifically, the focus on differentiating yourself from your competitors from a quality point of view once again utilizing the Targeted Growth Initiative to focus your Capital Expansion Programs, which you’ve demonstrated toward the end of your presentation, and your overall focus on people as being our most important asset. So thanks for that tour and I’d like to continue our traverse of the country toward the very Southeast, not including the Southern States Region as we move to Florida. Many of you who followed our story over a number of years have seen what I would call the ups and downs of the Florida region. And certainly, historically, Florida has been from a cost-management perspective, the number one region in the company. Secondly, as the population grew over many years, we maintained our market share but grew our
  • Tenet 2008 Investor Day Page 47 volumes considerably. But with the unpredictable acts of God and Mother Nature over the last few years, the landscape in Florida has changed dramatically and with that, we as a company, had to adapt and we adapted it in a number of ways. In early 2007, we made the decision to move from two markets into a combined single region. Second, through insights regarding our physician manpower needs, we elected to really accelerate the expansion of our medical staffs and to do that, we went outside the company to recruit a new leader for our very important Florida region where we believe that the future was even brighter than any time in the past. We were fortunate enough to find Marsha Powers who had spent over 20 years with Quorum Health Resources as well as Triad Corporation and at one time, actually worked for AMI, our predecessor company of Tenet Healthcare Corporation. Marsha joined us the beginning of the fourth quarter of 2007 and has provided significant energy and enthusiasm in the renaissance of the Florida region. So it’s my pleasure to introduce Marsha Powers. Marsha. FLORIDA REGIONAL REVIEW Marsha Powers Senior Vice President, Florida Region Well, thank you. And just like the rest of the company, our region’s success is completely and totally dependant upon serving our patients, like Mrs. Ramirez, and developing a long-term relationship with our physicians. We have ten hospitals in the Florida market; five of our hospitals are in Palm Beach County with a combined market share of 38 percent. We are the exclusive provider of trauma services and the largest provider of emergency room services in Palm Beach. We also have a children’s hospital as part of our St. Mary’s Medical Center. We have one hospital in Broward County and four in the Miami-Dade area. We are the number one provider of OB, neonatal and cardiovascular medicine in this area and we have a 41 percent market share in the North Miami area. Our network stretches over 85 miles and this allows us to provide a full range of clinical service convenience and geographical access that our patients need. We not only can meet the clinical needs of Mrs. Ramirez, but also the needs of her family and her friends. We are the largest provider of health services in the TriCounty from the number of hospitals, the number of beds, and also from a market share perspective. We’re the quality leader and we offer a diversified range of services. About one out of five admissions that occur in South Florida come to one of our hospitals. We are also the largest provider of cardiology, orthopedic, and OB services. The breadth and the quality of service we provide coupled with our long-term efforts to build relationships with our
  • Tenet 2008 Investor Day Page 48 customers and our physicians, like Dr. Cogan, has allowed us to improve upon our volume and our market share. The system that Tenet has developed and refined over the past few years has provided a comprehensive and competitive network. This provides us with significant negotiating strength with our managed care pairs as a must, must-have network and enhances our regional business strategy, including our best practice sharing. It avoids duplication of services as well as providing economies of scale. The South Florida market long-term demographics are favorable. We will continue to experience higher than U.S. average population growth in South Florida. And, of course, as Dr. Newman mentioned, we do have the lowest operating cost-structure in Tenet. Now, this is what we’re all about. We’re all about growing our market shares and improving our volumes. We’re going to accomplish this through our targeted growth initiative, our most important medical staff development, and our continued market leadership in quality and, of course, we will continue to drive our costs to improve our margins. These are the key strategies and tactics that will help us retain our existing customers but also help us win back physicians, like Dr. Cogan. Looking at our targeted growth initiatives, we have a fact-based and customized facility- specific diversification strategy. We’re focused on high-margin services and supplementing this with our physicians, manpower, development, and our alignment strategies. Cardiology, as most of you may be aware, has always been a very high margin service for us. We have further strengthened our cardiology services by adding electrophysiology services at our hospitals in Delray and Palm Beach Gardens. Oncology also remains one of our top five service lines responsible for inpatient hospital admission utilization. It also offers high, long-term growth and high contribution margin. We have the technology and infrastructure in place to include the Gamma Knife at our Good Samaritan Hospital and linear accelerators at our hospitals St. Mary’s and North Shore. We have strong relationship with high quality oncologists that we intend to continue working with and we’re also working with them to facilitate opening satellite offices at our other campuses. Our outreach efforts help us attract our new patients, like Mrs. Ramirez, and will help us achieve this goal. We have a relatively stable market share in neurosciences and in orthopedics. However, with our two major trauma centers already in place, we have the entire infrastructure required to support and grow these service lines. Our recent investments in stereo tactic neurosurgery inner operatives imaging capabilities and our specialized final instrumentation allow us to pursue elective neurosurgery and spinal business. We’re also working on stemming out-migration by functioning even more as a network in areas like cancer care, neonatology, stroke care, and by encouraging our hospitals and our physicians to work together. Our local EMS providers are re-routing expected stroke patients to accredited facilities with stroke teams in place. With our strong neurology and neurosurgical components and our excellent ERs and high-tech imaging, we think that we
  • Tenet 2008 Investor Day Page 49 can serve these patients. By the end of this year, we will have five stroke centers in place. This will allow us not only to defend our market share, but also to grow it. The outpatient environment in Florida has always been very competitive and we have been losing market share to the freestanding offices and physician offices. However, as we deploy our physician-employment strategy, we will use our clinic facilities to provide outpatient ancillary services to compete with the freestanding ancillary centers. Now, this is where the fun begins. This is the thing that we’re probably most focused on right now. As you probably are aware, South Florida has been experiencing significant shortages of positions for some time. So our medical staff development and alignment strategy is very, very key for us. This will allow us to bring new physicians into the market, to secure emergency room coverage, and we also anticipate that these new physicians will participate in more attractive commercial managed care plans. Now, when I arrived in Florida, I was actually very surprised by the lack of physician recruitment. I don’t think that the Florida Region had done any physician recruitment for almost five years. So Dr. Newman is absolutely correct when he says that our hospitals have lost anywhere from 10 to 40 percent of our medical staff. The good news is that we very, very much have the challenge in place for our hospitals and we are executing on this challenge. Now, South Florida is a very attractive place for physicians. Just looking at some of the physicians we’ve been bringing in in the last few months, it’s exciting to watch them look at the marketplace and see what’s there. We had a recent physician that came in and he met with the primary care physicians, toured the markets, and was just thrilled with the different services that he’s going to be able to provide and the fact that there is such an extreme shortage of physicians in this one specialty. He was just thrilled with the equipment at the hospitals; we have almost everything in place to make this very successful. We’ve also initiated the development of our Physician Leadership Groups. Our PLGs, as we call them, have been a very successful and disciplined way to meet with our key active staff physicians. We talk about our physician relationship program, we talk about recruiting new physicians into the market, we talk about relocating physicians into our market, but the one thing that we also are very, very cognizant of and want to make sure that we’re focused on is the number of physicians that could potentially leave our hospitals. When Dr. Newman put up the slide of the number of physicians that we’re recruiting, the number of physicians that are leaving our hospitals, we also think it’s very, very important to try and minimize the number of physicians that actually leave our facilities. And if you look at Dr. Cogan and what happened with our PRP program, our staff went to visit Dr. Cogan in his office, talked about the services that we’re providing, the things that we’re doing well, our quality scores. Well, we don’t want other hospitals to have that opportunity to do that to us so one of the things that we want to make sure that we do is that we have a disciplined and focused way to meet with our current physicians that are
  • Tenet 2008 Investor Day Page 50 on staff. On a monthly basis, we sit down with them and we develop a collaborative relationship, we talk strategies, we talk quality, we talk about things that we can do to improve how we’re delivering our care. And we do believe that that will help us mitigate physicians that potentially want to go to other facilities. So if you look at it, one of the things that is probably most exciting is that each month when I meet with our physician leaders, one of the things that I’ve been getting is as more and more time goes by, our physicians have come to me and said, “You need to meet with this doctor. He’s over at XYZ Hospital, he’s not happy, go talk with him, we can get him. We can get him to our hospital.” So a lot of it is not just recruiting new physicians and relocating physicians, but also making sure that we secure the ones that we have. So that is really one positive result of our leadership group. In addition, we’re also developing a primary care employment strategy. We’re developing a strong, primary care base. That’s one thing that in Florida we had relied upon for a number of years – a lot of our business coming through our emergency department – so one of the key focuses for us is developing a good, sound primary care base. And we’re also again employing physicians and we’re relocating physicians. Now, one of my colleagues mentioned the fact that new physicians coming out of training now do not want to set up practices on their own. More and more of the physicians that we’re interviewing in Florida want to be employed so we do have that as an option for our physicians. And again our employment strategy and our relocation strategy is all geared to support all of our clinical programs and our Target Growth Initiative. Over the years, Tenet Florida has done very well in positioning our hospitals in terms of providing quality services as well as getting recognized with the various organizations monitoring our care. Our facilities have been recognized by CIGNA – we have 54 Centers of Excellence; by United – we have 12 Centers of Excellence. We also have two hospitals that received the Triple Gold Award from American Heart Association. We have numerous designations by Blue Cross, the Centers of Excellence, and multiple clinical service lines. We have two state-designated trauma centers, three Joint Commission Certified Stroke Centers, and we’re also the overall market leader in quality as reported by CMS and by the state. We also had two hospitals recently named by HealthGrades as the top fifty hospitals in the United States; Palm Beach Gardens and Delray Hospital. So as you can see, when we compare our hospitals with our competitors in the market, on both the state and national average, our performance is materially better. Operational efficiency is very important. Despite being the lowest cost leader in the company, we will continue to drive multiple market wide initiatives to help offset increasing expenses. Our philosophy is to reduce cost by improving productivity, by reengineering processes, and negotiating better pricing relationships with our vendors. We obviously have no plans to impact any costs related to our direct patient care.
  • Tenet 2008 Investor Day Page 51 Although good short and long-term planning is important to our growth and the success of our business, accountability is the key to us staying focused and improving our results. Last year, we went through a collaborative process of developing our business plans and our budget. We did an excellent job of developing these plans and getting our hospital team’s commitment to deliver upon them. We also conduct monthly operational and financial reviews to ensure that everyone does stay on track. We also have quarterly business plan reviews and quality reviews to keep our teams focused and for us to monitor our progress and all of our key strategic initiatives. We do monthly patient and annual physician satisfaction surveys to ensure that our patients and physicians are satisfied and excited about our hospital. In summary, I hope that you are as excited as I am about all of our opportunities in South Florida. When you see our goals, our focus and discipline approach to our markets and our strong commitment to physician recruitment, you can begin to realize how important Florida is to Tenet. Thank you very much. Dr. Steve Newman Well, thank you very much, Marsha. I appreciate that enthusiastic review of the Florida Region and the great progress that has been made there over the last sixteen months. I think we learned a couple of things new. First of all, we learned that you added your own variation of the PRP program to the Physician Relationship Program. It sounds like you now have the Physician Referral Program where you use your own loyal doctors to help you go out and target active staff to join your hospital. Obviously, something that we’ll want to try in the rest of the company. A couple of other things. Your focus on continuing to improve a cost structure even though Florida historically has been the low-cost region throughout the company. So we really appreciate all the work you and your regional team and A-teams are doing in Florida. PHILADELPHIA MARKET REVIEW Stephen L. Newman, M.D. Chief Operating Officer For those of you that have not followed us closely, after Investor Day last year, we did a minor realignment of the regions and at Investor Day last year, we had five regions. Well, now, we have four regions and what’s happened is we have the Philadelphia market and based on my discussions with Mr. Fetter, I was left with Scott Richardson, our SVP of
  • Tenet 2008 Investor Day Page 52 Operations Finance in the back to be the regional leader for our Philadelphia Hospital. So it’s my pleasure to show you the truncated version of the Philadelphia Market Review. It was about three hours yesterday owing to my enthusiasm about the turnaround of these hospitals but we’ve cut it down all to make it even shorter in order to get to the Q&A session. So we complete our discussion of each of our hospital regions with an overview of the Philadelphia market. Many of you will remember that a short two years ago, our Pennsylvania facilities were considered part of the “but fors.” That is, when we talked about our volume earnings, we would include a “but for” our Philadelphia hospitals. Circumstances required a similar disclaimer for our Florida Region as well. Well, I’m pleased to report the “but fors” are gone due to dramatic improvements in this region. So let’s take a deeper look at the Philadelphia Renaissance. In Philadelphia, our two archetypical characters, Dr. Cogan and Mrs. Ramirez, were trying two Tenet hospitals, both of which are academic medical centers. They would see our largest hospital in the market is Hahnemann University Hospital, which is a tertiary care facility that’s affiliated with Drexel University College of Medicine. Hahnemann’s 541 beds make it the sixth largest hospital in the metropolitan area. Hahnemann was recognized last year by U.S. News & World Report as one of the nation’s leading institutions for heart care. Hahnemann also is a Level I Regional Trauma Center and specializes in advanced clinical services such as cardiology, organ and bone marrow transplantation, oncology, obstetrics, and gynecologic services. Dr. Cogan and Mrs. Ramirez would also recognize St. Christopher’s Hospital for Children, which is one of the two pediatric hospitals in the Philadelphia market. In addition to providing advanced care for children, St. Chris also serves as an academic medical center for both Drexel University College of Medicine and Temple University School of Medicine. St. Christopher’s has been nationally recognized through its sickle cell anemia and cystic fibrosis treatment centers and has the area’s only pediatric burn center. St. Christopher’s is seeing a strong increase in the number of patients it treats in part due to the closure of Temple’s Children’s Hospital. St. Chris also is providing some new services to the community, including pediatric bone marrow transplants, and has been expanding its surgery services to meet increased demand. If Dr. Cogan lived and worked in the Philadelphia market, he would have paid close attention to the recent negotiations of Hahnemann and St. Chris with the largest managed care company in the area, Independence Blue Cross. Since this managed care company accounts for more than half of the commercial covered lives in the greater Philadelphia area, it was very important for our hospitals to reach a mutually beneficial multi-year contract with this managed care company. Dr. Cogan also would be aware of the strong volume growth at Hahnemann and St. Chris and notice the strong growth opportunities in the five county outlying suburban area. Hahnemann’s location in the affluent Center City area in proximity to Rittenhouse Square would also be attractive to Dr. Cogan as he works to establish his practice.
  • Tenet 2008 Investor Day Page 53 As major teaching hospitals, Hahnemann and St. Chris are working with their academic partners to grow business and recruit needed medical staff members. Many physicians, like Dr. Cogan, are attracted to large teaching hospitals where they and their patients have the opportunity to participate in clinical research and work with colleagues as they teach tomorrow’s physicians. The faculty would also be a wonderful referral source for his newly-established private practice. Also important to physicians is the great deal of progress we’ve made toward improving the physical plant and technology at both of our Philadelphia hospitals. To meet the increased demand at St. Chris, the hospital is adding 18 inpatient beds and two operating rooms. At Hahnemann, we’ve made significant capital improvements, added new state-of-the-art equipment, such as electrophysiology and cardiac cath labs, nuclear cardiology equipment, and robotics and echocardiography. The capital improvements have been designed to allow both of these hospitals to deliver consistently good patient experiences. According to the most recently published CMS data, Hahnemann’s overall quality scores far exceed national, state, and local averages. This type of data is becoming increasingly important as physicians like Dr. Cogan and patients like Mrs. Ramirez make decisions about which hospital in the Philadelphia market they would choose. Because the hospital compare Web site uses data only from adult patients, pediatric hospitals like St. Chris today don’t have this same type of comparative data but it is coming in the near future. Thanks to physicians like Dr. Cogan and patients like Mrs. Ramirez who have chosen Hahnemann and St. Chris, both hospitals are showing a strong body of growth in inpatient admissions, outpatient visits, and surgeries. The two hospitals have increased inpatient admissions by 13.4 percent over a prior year. Surgery volumes increased 22 percent while outpatient visits grew by 10 percent. From an operational improvement standpoint, the average length of stay decreased by nearly 3 percent and our supply cost per adjusted admission decreased by 12 percent. As shown, the indicators for the two hospitals in Philadelphia are all heading in the right direction and have resulted in positive impact on the bottom line. New physicians are being added to the medical staff process. This is resulting in some new services being added. At both facilities, a strong hospital leadership is maintaining good relationships with physicians, hospital staff members, the community, and most importantly, the patients. So to summarize, both Hahnemann and St. Chris have shown significant volume growth, we recently signed a multi-year agreement with a major managed care provider that has more than 50 percent of the area’s covered lives, both hospitals are emphasizing their Targeted Growth Initiatives, and they’re using quality clinical performance and excellent patient satisfaction to bolster their place in the market. As academic medical centers, their strong relationship with their primary academic partner, Drexel University College of Medicine, helps in many ways, including medical staff development, recruitment, and tension. Thank you very much. This completes our regional review and I’d now like to open the floor for questions for our regional team that may have struck you during the
  • Tenet 2008 Investor Day Page 54 presentations this morning. There are microphones in the back. If you’ll just wait a second, we’ll come to you. REGIONAL REVIEW Q&A SESSION Q. Thank you. Adam Feinstein with Lehman. And thank you for the overhead – very helpful to hear the strategy in the different regions. I’m just curious. In prior years, you’ve given updates in terms of just how the operations have done in other regions. So, you know, it’s one thing to hear the strategy but it’s another thing to hear, you know, what’s going on with some of the major industry trends like you mentioned new contracts in the Philadelphia market but just, you know, any updates in terms of volumes, bad debt, uninsured trends, competitive landscape. Just curious if you could just provide a little bit more info on any of the regions where you could give us that data. A. (Dr. Newman) Well, last year at Investor Day, we provided some aggregated data graphs by region over a period of years in response to a specific question that had been asked sometime prior to Investor Day. This year we thought we would give you a little deeper understanding as to how the individual regions are bringing to life the strategies and tactics that we’ve outlined in our quarterly conference calls. I think along the way, we’ve shared information about the regions but we didn’t plan to give a region-by-region review of how we performed along those metrics, whether it’s net revenue or admission by region or overall cost per region. But we’ve given you some directional information in terms of what’s low cost, where we have high or low bad debt, and that sort of thing. So I think we’ll probably stand on that for this presentation and take your question under advisement for the next Investor Day. Q. (Adam Feinstein) Can I ask you another question? A. (Dr. Newman) Sure, considering I didn’t answer your first one. Q. (Adam Feinstein) Yeah, right. Thank you. Maybe just curious then to talk about just the reimbursement outlook at the state level with state Medicaid programs with the different states having budget deficits. Particularly interested in California – there’s been a lot of noise out there. So just curious in terms of any updates. Be curious to hear about California, Texas, Florida, and any other key states where there’s any major changes that could happen in the future. Thank you.
  • Tenet 2008 Investor Day Page 55 A. (Mr. Flocken) Well, let me start with California. Actually, Biggs is going to provide some commentary I think in his presentation later about some specific financials and numbers but within California, one of the issues is certainly, you know, the issue with the budget and the impact on the Medicaid program. But California uniquely in many areas operates under a federal waiver. And one of the issues is in order to implement some of the changes that the governor is proposing, you actually have to go back and get approval from the Feds to implement those changes. And they have not even approached and begun to do that so the scope of the actual cuts that can administered directly by the state is somewhat limited and again Biggs will provide some color on what we know about specific numbers later in his presentation this afternoon. Dr. Newman: John, anything about Georgia Medicaid? A. (Mr. Holland) Well, I believe we’ve already discussed the impact that the changes in Georgia have had on all the hospitals in Georgia as well as in North Carolina. So I think those are well known and we’ve kind of baked those into our performance standards. Dr. Newman: Bob. A. (Mr. Smith) Yeah, thanks for the question, Adam. In Texas, we are also now going to seek a waiver – that’s in negotiation right now – with the Feds and we really took our hit in 2003; there’s a big take back because of state budget crisis then, but there is a budget surplus now in Texas irrespective of what’s going on with the economy nationally. The Texas economy is doing quite well. So we expect some improvement. We’re on a buy-in and the last legislation was 2/07 so the next will be obviously ’09 and so we expect some improvement in the ’09 session. And what the state is focusing on now – our current governor and lieutenant governor – is creating what they call a health opportunity pool to try to get more uninsured people covered. Rather than providing bigger rates for Medicaid, they’re looking to try to spread the love if you would and try to cover more people with the health opportunity pool and that’s all part of the waiver process we’re going through. Dr. Newman: Marsha, Governor Crist and the legislature in Florida seems to be very active today. You want to update the group on that? Ms. Powers: I think everyone is probably well aware of the issues in Florida from the property tax and from the revenue cycle. One of the things that the governor has done though is he has recently proposed a way to cover the uninsured through a low-cost health plan. Not real sure on the details but obviously from our concern, our standpoint, any way we can get our uninsured covered in any way not only for us but for our physician practices, you know, it is certainly welcome.
  • Tenet 2008 Investor Day Page 56 Dr. Newman: Great, next question. Darren. Q. Yeah, it’s Darren Lehrich from Deutsche Bank. John, I think you had mentioned something about a deferred comp pilot that you are looking at. Can you just expand a little bit more on that? It sounded like something. A. (Mr. Holland) Yeah, it would be very similar to what you all have seen with the Executive Deferred Comp Plans where you would have a vesting schedule. Physicians who take call would in effect participate in a deferred comp plan that would vest over, usually a five year period, and it helps them and helps us, so it’s a win-win situation. We are piloting it at three hospitals; we don’t have it in place yet but we will have it in place in two hospitals this year and looking at that one by January 1. So it will be exciting to see the impact it has. Dr. Newman: So, John, tell them a little bit more of how it works and locks the doctors in the right coverage for much-needed (indiscernible). Mr. Holland: Yes, it’s part of the plan. The participating physician has an agreement with each hospital to provide that coverage. If the physician, for instance, leaves the area or decides to quit practicing at that hospital, of course, the deferred comp funds that have build up tax-free are at risk and the physician would forego that if they left. So it’s a good way of developing our medical staffs and retain them and give them an option to grow their, in effect, investment egg tax-free and for those of you who – a lot of physicians just don’t have any way to do that effectively today. And so it’s a vehicle that we think will have a lot of traction in a lot of our markets in particular. Q. (Darren Lehrich) My next question, the salary and benefit savings you referenced I think $12 million over four months, but can you just give us some more detail on where that’s coming from and then what that is? A. (Mr. Holland) Sure. This is part, I think, the good part of being in a fairly large company with a number of resources. We were able to use – we saw an opportunity honestly to improve our operating performance in SW&B. We used resources both internally and our friends down in Florida who run a very efficient – obviously have for a number of years – a very efficient cost structure. We applied some of those resources to a number of our hospitals and were able to very effectively improve our cost metrics and so. And that’s a combination – some of our hospitals, it was internal consulting engagements. We have a group called PMI that actually functions in that way. We had that group in six of our hospitals and in other facilities where it was a – we didn’t need a major restructuring of the cost structure, we simply needed to make sure that our labor management standards were applied appropriately. And in those cases, we saw a lift from that so that was through the 12 hospitals. Dr. Newman: Sheryl.
  • Tenet 2008 Investor Day Page 57 Q. Thanks very much. Sheryl Skolnick from CRT. I’m struck by something as I’m sitting here and I’m listening to this. I’m trying to step away from the individual key metrics and our, you know, innate focus on fines up, fines down, bad debt up, bad debt down to sort of sit back and try to sense the tone and sense the direction and sense an overall big picture. Am I right that you’re no longer managing from crisis to crisis? Am I hearing sort of a more normalized consistent execution- driven strategy of a more normal hospital company growth story? Is that possible? I mean, you know, it’s bad for me to be the one saying this because I have a “buy” rating on the stock. I would rather this be said by somebody who can be viewed as maybe being more objective but, tell me, is that the way I should be looking at this? Is that the message you want to deliver and what would be the negatives here? Dr. Newman: I think that’s exactly what we’re doing and clearly our culture has changed over the last five quarters under Trevor’s direction and leadership because we put those sort of bad days behind us. We don’t have a crisis mentality; we have a sense of urgency of dealing with issues that arise but in some ways, we’re spending a significant amount of our time crafting the future while we’re managing today. And I think that’s a big change because for so many years, between 2003 and 2007, we had to put all our resources on putting out fires and managing today so that we didn’t really have a lot of time to spend on creating value for the future. So I think you very eloquently stated what we’ve spent three and a half hours to say today and that is that we believe we have a better handle on our business than we’ve ever had. We understand it more deeply. We have the infrastructure, we have the talent, we have the people, we have the systems, we have the business intelligence to not only manage today but to create increasing value for the future and that’s our focus and that’s where we’re going. Q. (Sheryl Skolnick) Okay, that’s great. Now, can I go back to a little detail? Dr. Newman: Okay. Q, (Sherly Skolnick) Because that’s what they pay me for. So one of the little details that I noticed I think was that AMC could use a little help on the quality initiative and I find it interesting that you focused on that one in your sort of doctor/patient interlude. So can you talk to me about what some of the issues might be there and then the second nit that I’m going to pick is as I understand it, there were sort of three hospitals within the system that you talked about in the first quarter. Obviously, those that were not so wonderful in terms of commercial managed care – they were responsible for 50 percent of the decline. One of the five of you up there manages one of those three hospitals. So whoever wants to raise their hand and say, “I’ll take responsibility.” Can you tell us specifically since you can identify – you have the business metrics – what are some of the issues that you’re
  • Tenet 2008 Investor Day Page 58 facing and how are you better today at dealing with them say than you were a year ago? Dr. Newman: Let’s let John answer the AMC question. A. (Mr. Holland) Let me answer the AMC question. That was put in there actually for you to catch that. No, we obviously – AMC in particular and all of our hospitals, we compare very favorably to our competition. It’s obviously one that we want to get up above the Georgia average and above the national average and we applied a lot of, I guess, software and hardware to do that and we are improving. But I think also Atlanta Medical Center’s one of our hospitals that’s growing. It’s seen significant increases in managed care business and across the board and, frankly, from a service/client standpoint, it’s been one of our very good performers. So I think in comparison to what it has to deal with in Atlanta, it’s doing very well. And I guess out of the 12 hospitals, we had to have a couple that were failing but we have a good strategy to get them back up to speed as well. Dr. Newman: Why don’t we let Bob answer the second question because he has one of the hospitals of the three that you referred to, not revealing anything specifically. Bob, you want to talk about that. A. (Mr. Smith) Thanks for that question. In Texas, it is a different issue. In Texas, and I said earlier in the presentation, there is no Certificate of Need, a barrier to entry and so in one of our markets in Houston, we had a group of over 80 physicians move a mile and a half away from the hospital and build their own hospital; not with another hospital partner, but a freestanding employee doctor- owned facility and they opened that at the beginning of January of ’07. Well, clearly there’s an economic incentive for those physicians to divert those more high-paying, high-margin patients to their facility. So what do we do in response to that? We knew that was coming. They came not only from our facility but from other facilities in the area to build their hospital and we used the TGI roadmap. Maybe we’re over drilling that but we began in 2004 knowing that the physicians were on this lead to develop their own facility and we began investing prudently in the hospital. We built a new ICU, we expanded the emergency room, which were key product lines for that facility, we added open heart surgery and deeper cardiac services, and now we’re in the process of expanding the Neonatal Intensive Care Unit and so we invested through the competitive issue. We also in that market created the 501(a) Physician Employment Model, which reemerged first in Texas so we have four locations with eight physicians – primary care doctors – away from the hospital. Also developed a freestanding urgent care center in the market as a means to control the channel of business into the facility. And so if you look at it today – in fact, I had an email this morning to your question – and I will tell you for the month of May that the commercial business is improved, the
  • Tenet 2008 Investor Day Page 59 uninsured business has declined, and that facility is looking much better and has a strong future right now. And really the decline we expected on earnings there, because of the way we went to the TGI and the reinvestment process, didn’t occur to the dark degree that we thought would happen. Dr. Newman: Thanks. Last question for this session from Kemp Dolliver. Q. (Kemp Dolliver) I’ll try to squeeze in a couple of quick ones. Steve, first on your supervision of Philadelphia, is that a long-term solution or are you looking to bring in some, you know, have some internal candidate take that over ultimately? A. (Dr. Newman) I think we’re very committed to our Philadelphia assets. You know, we’ve been through a roller coaster ride in Philadelphia since 1999 and we’ve divested a number of those facilities but we could not identify three- to five-year plan for success. But based on the last 18 months of focus, we’ve created significant value. We’ve embarked upon new services, we’ve improved our relationship with the payers in the market, we’re moving toward great parity in that market from a very low level. We’re not at great parity yet but Clint and his team, working with our leadership in Philadelphia, made great progress this year; we expect even more progress in coming years. So we are committed long term to that. We have a very good relationship with Drexel University College of Medicine and a budding, although smaller relationship, with the Temple School of Medicine. Q. (Kemp Dolliver) And in California, it looked like the data now excludes USC. Is my observation correct? And to what extent is excluding USC impact some of your profiles, such as say your uninsured mix, etcetera, since sometimes the AMC’s recited as being a magnet for that, for instance. A. (Dr. Newman) Well, you had a couple of questions in there. You asked about the uninsured as it related to USC. USC is what’s fairly unique in a number of aspects. One, its service area. If you look at it on how it draws patients, it draws onesies and twosies from a lot of zip codes around all of Southern California. There’s not a concentration around the hospital, per se. Also, the hospital doesn’t operate an emergency room and doesn’t operate obstetrics service so everybody who comes in there predominantly comes in as a vertical patient, so to speak. So really in terms of those demographics, overall performance is not going to have much impact at all. Dr. Newman: All right, Tom. Thank you. It’s time for lunch. Lunch is in the room right behind us. We’re going to reassemble here at 1:00. I’ll re-announce what I announced at the break that we have assigned tables for each of the speakers that you saw this morning. Their names are on the tables. If you want to have a conversation with them over lunch, just look for the sign. We’ll be back here at 1:00. Thank you.
  • Tenet 2008 Investor Day Page 60 (Lunch) Ladies and gentlemen, please take your seats. The program will begin in a few moments. Trevor Fetter That was so official. All right. Well, we’re ready to resume. We’ve got an active schedule this afternoon and our first speaker now after lunch – tough spot, Richard, to be after lunch – is Richard Yonker who is our Vice President of Corporate Sourcing. Richard is so good at what he does that when I started Broadlane in 2000, I recruited him to join our team there and I’m very fortunate that after coming back to Tenet, he was willing to leave Broadlane and come back and run all of our source initiatives. He continues to do an outstanding job managing the supply chain and keeping our costs low. I received a number of questions at lunch about initiatives in this area and I’m very pleased – because I’ve seen your presentation – to know that you are going to be answering all of them. Richard. SUPPLY CHAIN MANAGEMENT Richard Yonker Vice President, Corporate Sourcing Good afternoon. And I do get the lucky spot of being after lunch so I’ll try to keep this – I mean, it is the Supply Chain so that’s exciting enough, right? Right. All right. I’m responsible for Tenet’s Supply Chain Operations and as many of you probably know, that touches a lot of different areas from our daily procurement processes and support systems, inventory management, contract and vendor management, supplies, services, and capital equipment. And of special importance to all of you, our cost control efforts in all our major expense categories. These efforts are critically important to ensure we have access to the capital needed to equip our hospitals with the latest and best medical technology and resources to enable us to meet the needs of folks like Dr. Cogan and patients like Mrs. Ramirez. Today I will share the details of two of our many ongoing cost-reduction initiatives. The first will be our Medication Use Management program, also known as MUM. This program allows us to control our pharmaceutical expenses through appropriate use and standardization of key high-cost drugs. The second area of discussion this afternoon will be a review of our efforts to control the rising costs of orthopedic and spine implants. As you know, many hospitals struggle with
  • Tenet 2008 Investor Day Page 61 strategies to address these costs. I will update you on our approach and share some interesting facts on this challenging market. Let me begin with review of the Medication Use Management program. MUM focuses on reducing pharmaceutical costs by addressing how medications are being used within our hospitals. This assures the highest level of care for our patients and at the same time allowing us to operate as efficiently as possible. The first step in the MUM program consists of an evaluation of pharmaceuticals to determine whether drugs within a given therapeutic class can be standardized. We also evaluate our highest cost drug categories to determine how and when they are being used. The goal is to ensure usage in the most appropriate and cost-effective manner. Based on this MUM evaluation, opportunities for standardization and/or utilization improvements can be identified and implemented. The standardization process within MUM begins with an analysis of a class of clinically equivalent medications. Based on this information, we select one or two products to be the preferred agent in that drug class. Standardization within a medication class also allows our hospitals to decrease the amount of pharmaceuticals that are managed at each hospital. This supports a safer environment because it allows for fewer medications to be controlled while giving our hospitals the opportunity to optimize the process. To determine the proper utilization of a medication within the hospital, we also use the MUM process. As a result, protocols, guidelines, and appropriate use criteria are then developed for select high-cost drugs. After approval by local hospital medical staff committees, these procedures are implemented to ensure that medications are being appropriately utilized to provide patients with the highest level of care. Currently, we are in the midst of our fourth wave of MUM and over the last three years, the efforts of our directors and pharmacy have been outstanding. This wave of MUM has focused on examining and controlling utilization of high-use and high-cost medications as well as identifying alternatives for utilization in shortage situations. Key therapeutic categories included in this phase are anticoagulants, which are blood thinners like Lovenox® and Arixtra®, and hematopoietics, which are “blood boosters” like Procrit® and Aranesp®. Regarding blood thinners. Due to the develop and implementation of new industry-wide patient safety initiatives, such as the Surgical Care Improvement Project and the National Patient Safety Goal (3E), anticoagulants continue to be one of the top ten pharmaceutical cost areas within our hospitals. These quality measures emphasize the importance of the prevention of blood clots in hospitalized patients and create the need to ensure patients are correctly identified as being at risk to receive the recommended amount of anticoagulation. In response to this, we have implemented new protocols, criteria, and guidelines to address these changes within all Tenet hospitals. This ensures that all of our patients are receiving the same high level of care.
  • Tenet 2008 Investor Day Page 62 In the area of cancer medications, the use of hematopoietic agents was in the spotlight during 2007 and has remained there throughout this year. Current medical literature has brought attention to the safety of these agents and patients with certain cancers and those with renal failure. This has led to increased scrutiny on how these agents are used. The one message that has been consistent in the literature is that patients receiving these medications need to be closely monitored to prevent them from experiencing adverse effects from too much medication. As a result, Tenet made the decision to convert to the shorter-acting medication within this drug class and has developed dosing and monitoring protocols to help ensure its safe and effective use. As well as increasing patient safety, this has also reduced the cost in this area. These are just two examples of the initiatives that has been completed by the pharmacy departments within Tenet under the MUM program. As for the results, since early 2006, we have been able to decrease our pharmacy cost for adjusted patient day by 4.1 percent; all of this given the fact that the industry has seen annual increases of four to six percent over the same period of time. The current wave of MUM launched in August 2007 has saved Tenet $9.4 million in its first nine months. This is in addition to the success of the previous MUM waves, which brings the total savings to the program to almost $83 million over the past four years. This program has and continues to help decrease the inflationary impact on pharmaceutical costs and instead of the observed four to six percent annual inflationary increase seen nationally in the acute care setting, Tenet has held our pharmacy expense flat for three years. While the primary focus of the initiatives I’ve just discussed is on controlling cost, these initiatives also improve the quality of our clinical care and therefore the patient outcome. As a result, physicians benefit from both improved patient satisfaction and lowering their malpractice risk. Now, let’s talk about our recent efforts to control cost in orthopedic and spine implants. This has been a very challenging area for hospitals for more than ten years. According to the Orthopedic Network News, a quarterly publication and database in orthopedic pricing, the list price for a “coated” hip implant increased by 204 percent from 1991 to 2008 and the average selling price for a total hip increased 132 percent in a ten-year period from 1996 to 2006 and data from January ’08 indicate that list prices are still rising but the 6.3 percent increase from early 2007 to 2008. Compare this to hospital Medicare reimbursement payments that have increased only 27 percent from 1991 to 2008 and during that same period of time, physician reimbursement has fallen by 39 percent. As you can imagine, this imbalance between cost and reimbursement creates a problem for our industry. So what are we doing to address the issue? Tenet’s strategy to address rising costs is fairly simple. We are using a local hospital-by- hospital or “foxhole-by-foxhole” approach to negotiate better local pricing while maintaining choice for the implants our physicians prefer. Although our approach is simple, the work to build the data sets required to support these efforts is very time
  • Tenet 2008 Investor Day Page 63 consuming and rigorous. We begin our process by collecting invoice and procedure level data to build detailed implant utilization profiles by physician and by hospital. At the same time, our local 18 members are meeting with key physicians to discuss the negotiating strategies. This is a critical step given that once the vendors are contacted, they typically run out to their doctors and they attempt to stop our process. With active A-team participation and physician support, we use the implant-specific cost profiles to develop custom matrix pricing models that are used in the negotiation with our local ortho and spine vendors. After successful negotiations, a critical implant monitoring and reporting process begins. Monthly reports containing detailed vendor invoice data are generated at the corporate level and shared with the hospitals. This process will continue for a minimum of a year to ensure our business partners are living up to the terms of our agreement. As a point of reference, our ortho spend last year exceeded $115 million and is one of our fastest-growing areas of expense. The good news is that we do have some early positive results in those hospitals where we have begun the most recent negotiations. So far, we are working with 32 of our hospitals to complete this process. The anticipated impact is a 20 percent reduction in our current prices and we should see these reductions in a few hospitals within the next couple of months. In closing, I would like to remind you that the supply chain function within Tenet touches many different areas. We focus intensely on areas of cost-control and improved quality tied to the products we purchase. It is our mission to operate as efficiently as possible to allow Tenet to provide quality care with the latest technology for our patients in supporting the needs of our physicians. While I’m not going to stand here today and tell you that I personally get a lot of pats on the back from all of our physicians, I can tell you that there is no question that physicians view this as the right way to operate a hospital. Physicians like to be associated with a successful organization and they know that effective control of our operating costs is directly linked to improved financial performance, which in turn strengthens their view that Tenet will thrive over the long term. I thank you for your attention today and I’ll turn it back over to Trevor. Trevor Fetter Thanks, Richard. Our next speaker is actually the longest-tenured executive at Tenet on our team. Steve Brown, our Chief Information Officer, has been with Tenet and its predecessor company AMI since 1976. He’s worked in hospitals, he’s worked in the corporate office, and he’s been Chief Information Officer since 1990. In that time, Steve has led the company’s efforts to develop an integrated and advanced platform for information and telecommunication systems. He knows hospital operations inside and out. He’s incredibly pragmatic about his approach to the job. In fact, those of you who have watched us for a long time have noticed that we’ve never had any major IT write-
  • Tenet 2008 Investor Day Page 64 down. Steve is the key member of the leadership team, and he’s going to talk to you today about some really innovative and exciting new technology to support the strategies that you heard about this morning. Steve. REVENUE CYCLE Stephen Brown Chief Information Officer Thank you, Trevor. Well, over the next 15 minutes, I want to build on our discussion from last year, and pick up the Information Systems story, using Mrs. Ramirez and Dr. Cogan to illustrate how information technology is supporting our patients and our physicians. Last year, in speaking to this audience, I reviewed the very broad scope of information systems activities for Tenet. Information Systems was and is an important element in all aspects of our business. We remain focused on the key priorities of the company and have demonstrated excellent information systems capabilities. Tenet has excellent clinical quality monitoring systems. We continue to successfully roll out our integrated frontline clinical systems. We have excellent physician facing information systems and consumer facing information systems, and we continue to expand on these capabilities. We clearly have high-performance revenue management systems. And we have excellent back-office information systems in areas such as labor management, supply chain management, logistical support, and asset management, and the many aspects of our business intelligence capabilities. But today I want to focus on the customer experience from an IT perspective. Information Systems is playing an increasingly important role in guiding patients to our affiliated physicians and to our hospitals for services. Consumer-oriented information systems also play an important role in supporting the patient and patient’s family during and after hospitalization. Some of the information systems I will discuss include patient self-diagnosis tools, the physician referral system, communicating clinical quality, customer access to hospital services and education, health condition education, patient preregistration tools, patient kiosks that streamline the admitting process, free Internet access in our virtual nursery system, and lastly, our online bill-pay tool. Tenet uses a plug-and-play model for our Web sites, and each hospital can implement any or all of these systems. A prospective payment, such as Mrs. Ramirez’s, could have begun the journey that connected her to our services through our hospital Web site experience. The journey usually begins with a question, and the question usually is, “I have a medical concern, but I’m not sure what kind of doctor I need to visit.” Tenet Hospital Web sites include an interactive diagnostic tool to help answer that question. MyElectronicMD helps determine what their symptoms might mean, and then
  • Tenet 2008 Investor Day Page 65 guides them through a basic diagnostic protocol. Year-to-date, MyElectronicMD application has over 18,000 visits. The diagnostic tool uses pictures and simple questions to guide a patient through a process that leads to a range of possible diagnoses. This is essential information that is then used to point toward the type of physician they need to see for further evaluation of their medical condition. The critical linkage for Tenet is that once the patient understands the kind of physicians they need to visit, we present the appropriate Tenet-affiliated physician referral links. This sets up an easy, actual event for the patient to schedule an appointment. Once the type of physician has been selected from a list of qualified physicians, Mrs. Ramirez is presented with a variety of appointment-scheduling options. She can electronically request a call-back from the physician’s office. She can directly call the Tenet Call Center via the toll-free number. In this option, the call center will assist her with scheduling an appointment. Lloyd Mencinger discussed this earlier. Or she can choose to simply call the physician office using the office hours and phone numbers we provide. This process provides a good service for the patient, but also provides a direct link for patients to our affiliated physicians. Year-to-date over 170,000 physician searches have been completed through the Tenet Web sites. Another purpose of the Web site is to provide clear information on the quality of services offered by the hospital. Mrs. Ramirez can visit the “Our Quality” section of the Web site to view hospital clinical quality results. With these clinical scores, she can gain confidence that the hospital is a high-quality services provider. The fact that healthcare searches are among the most frequent of Internet activities indicate the highly motivated population of potential patients. Our Web sites address this need for information and education with a variety of online tools. We utilize prepared course materials as well as a variety of health calculators and quizzes. These tools are designed to support various health conditions and to expand knowledge about the patient’s health concerns. Our hospitals’ Web-based educational content and tools average nearly 10,000 visitor sessions and over 20,000 page views per month. Some prospective patients want to learn more about the types of services the hospital offers. That exploration may lead to joining a specific hospital-sponsored event. From the Web site, Mrs. Ramirez may choose to register for events or classes related to her specific condition or area of interest. Online event registration is simple, and lets our hospitals understand what services prospective patients are interested in, and allows us for appropriate follow-up. Year-to- date nearly 3,500 online event registrations have occurred through Tenet Web sites. Our hospitals are also getting more creative in explaining our services, and in some cases are using full-motion video and 3D virtual tours to tell a more compelling and complete story.
  • Tenet 2008 Investor Day Page 66 We always desire to streamline the patient registration process. This is often a key factor in how the patient perceives the overall quality of the hospital experience. As such, we offer online preregistration to streamline the check-in process for patients and to streamline the process for the hospitals’ admitting departments. Year-to-date we’ve had over 3,100 preregistrations completed through the Tenet Web sites. Ron Kelley from our Patient Financial Services Group will discuss this in more detail during the next presentation. In addition, as Bob Smith mentioned, after the patient arrives at the hospital, we are providing kiosks and tablet PCs in the registration areas to streamline the admitting process. Ron Kelley will also discuss the benefits we are seeing from these excellent systems in more detail. While the patient is in the hospital, it is important to support effective family communications. And since many people communicate through e-mail, instant messenger, and instant messenger services and many other broadband services, most Tenet hospitals now have facility-wide free Internet services. Forty-two Tenet hospitals have these services today, and eight more will be completed by the end of this year. We also continue to look for ways to use information technology to support the patient through important life events. And one of the most important events is childbirth. Our relationship with the Growing Family organization allows us to offer a virtual nursery service. This photographic service presents baby pictures that can be securely accessed through our Web sites. Parents, family, and friends can view the new baby, baby pictures, order photos, purchase gifts, and can leave messages for the family. Lastly, after receiving services at a Tenet hospital, patients like Mrs. Ramirez have the option to pay their bill online. Online Bill Pay is an automated bill payment application that enables patients to inquire about the status of their accounts and pay outstanding balances using a secure Web-based platform. Ron Kelley will also discuss these systems in more detail during the next presentation. This new capability, and others that I’ve mentioned, are all part of Tenet’s “easy to do business with” philosophy. And while our consumer Web sites have won many awards, we continue to push forward with the tools that will both support our current patients and help recruit new patients for our hospitals. We are currently evaluating offering online personal health records in a more integrated model for establishing appointment requests for our physician partners. Also, a project that’s underway to enhance the tools local hospital staff use to update the Web sites with new graphics and keep them fresh and interesting. A typical experience for a Tenet-affiliated physician such as Dr. Cogan might begin with a referral from the Tenet Call Center. I walked you through how Mrs. Ramirez might interact with Tenet. Now I want to describe how Dr. Cogan might interact with a Tenet hospital.
  • Tenet 2008 Investor Day Page 67 Through our substantial array of tools and processes involved, we have made significant investments over the past several years to deliver the most important tools physicians have told us provide them with the greatest value. I will now walk you through a few key areas such as patient scheduling tools; the emergency department; single sign-on; the Tenet Physician Portal, which supports a variety of key functions such as patient location, clinical results, medications, medical images. And lastly, I will discuss the medical chart electronic imaging and signature system. One of the first issues for a physician, or more importantly, the physician office staff, is the ease with which a patient can be scheduled for an appointment at the hospital. Many of Tenet’s hospitals use a centralized scheduling capability. With one phone call, a physician or patient can request multiple procedures or services within a hospital. For the physician, the appointment process is streamlined and comprehensive, and the patient’s experience is improved by providing a convenient and coordinated visit. Some of the system capabilities include scheduling logic that supports all hospital services, resource optimization and conflict identification based on clinical rules, physician preferences and technical resource availability, streamlining of the admitting process through preregistration and integration with Tenet’s patient accounting system. Today we have 40 sites with enterprise scheduling, and seven additional hospitals will be completed by the end of the year. While scheduling visits is the preferred way patients access Tenet hospital services, the practical reality is that many of our patients also arrive unannounced through the emergency department. Effective operations in this department can create important customer perceptions of the hospital experience and are important to all physicians practicing at the hospital. As John Holland mentioned earlier today, emergency department systems improve physician productivity by integrating documentation between nursing and physicians, producing legible charts, easing physician transcription, and improving billing practices. Patient satisfaction increases because of shorter wait times and improved overall operational efficiency. Some of the system capabilities are rich, interactive graphics, showing the status of every patient in the emergency department; one-touch order entry that uses clinician-friendly terms to support bedside patient care; real-time laboratory and radiology status updates, including wireless alerts for laboratory results, alerting for duplicate orders, high-risk conditions, allergy, and drug interactions; and complete documentation and clinical decision support for both nurses and physicians. Tenet has deployed 32 of these systems, and has 16 more planned over the next 24 months. Now, once a patient is in the hospital, the care process begins to create vast amounts of information that must be reviewed by the physician to effectively guide the patient through the diagnosis and treatment processes. Electronically capturing this information and allowing anywhere, anytime access allows the physician to make more rapid decisions, and increases their productivity.
  • Tenet 2008 Investor Day Page 68 The ease of access and ease of use of these tools are critical factors in delivering a successful physician experience. The single sign-on capability allows physicians to use one ID and one common password to support streamlined access to all Tenet applications. Forty-two Tenet hospitals are live with single sign-on, and all hospitals will be live by the first quarter of 2009. The key information systems tool for the physician is the Tenet Physician Portal. Tenet’s Web-based physician access system provides a unified, anytime, anywhere, secure-access site for current clinical and operational information. This system is designed to integrate multiple sources of clinical and operational information and support a one-stop information market for both physicians and physician office staff. Using this tool, Dr. Cogan could access the Tenet Physician Portal and quickly review his current patients within the hospital and scan their recent results. He could also review Mrs. Ramirez’ recent visits for her medical history that could be relevant to her current situation. Some of the key capabilities of the Physician Portal are: patient location, demographic and insurance information, encounter history, clinical results such as laboratory and radiology, current medications, medical images, and direct access to electronically stored medical records. Physicians can also access over 35 clinical reference libraries and patient education materials. Today we have over 7,000 registered Physician Portal users. This is a 75 percent increase over last year’s count. Patients like Mrs. Ramirez could arrive at the hospital for an MRI. In that event, the digital image would be immediately available for reading by the radiologist. The radiologist could view the image and digitally dictate his findings. This reading could occur virtually anywhere in the world. Upon the completion by the radiologist, the image and result are immediately posted to the physician portal. Dr. Cogan could access this image, and after reading Mrs. Ramirez’ result and viewing the image, could discuss the findings with the radiologist, while both physicians view the image at the same time. Tenet rapidly deployed PACS systems to almost every hospital over the past three years, and this effort has provided significant benefits for our physicians. These include more efficient workflow and dictation integration, faster turnaround times due to remote access by radiologists, and elimination of both lost films and lost results. We continue to build upon this technology, and today seven Tenet sites have now implemented Cardio PACS. This technology is similar to regular PACS, but supports full-motion video such as that used in cardiac catheterization. Document imaging is another important area where we provide productivity support tools to our physicians. Tenet uses a commercial medical record document imaging system to support anytime, anywhere electronic access to post-discharged scanned medical records. This system provides remote access for physicians to review and electronically sign patient charts upon discharge. This system is live in all but one Tenet hospital, and that hospital will be complete by the end of the year.
  • Tenet 2008 Investor Day Page 69 In the physician support area, there are many new and exciting technologies that may yield value, but this area is also fraught with many challenging technical issues and high costs, so we do proceed carefully. Pilot testing has long been the Tenet way to make steady progress while managing risks, and we have several areas of research currently underway. These include: in the next few months we will launch pilots to provide clinical data to our physicians’ PDAs, phones, and/or other handheld tools to provide mobility and portability for our Physician Portal. We will also launch a pilot for our employed physicians that delivers a full physician office-based electronic medical records system linked to our hospital-based electronic medical records system. Lastly for this year, we will also pilot a push technology that provides real-time feeds of results directly into an affiliated physician’s electronic medical record. Our goal in all these investments is to make our hospitals the preferred place for physicians to practice medicine. Consistent with Dr. Newman’s focus on cost management, Tenet’s ongoing IT operating costs and the investments required to create and implement these information systems are very cost effective. The key principles behind this efficiency are: information systems and applications are standardized across hospitals. We utilize outsourcing for virtually all IT requirements, including shared, centrally hosted data centers, centrally run applications, and end-to-end support. Standards and centralization allows us to use shared experts to support multiple institutions and hospitals. And we use a blend of both onshore and offshore IT staff to deliver low-cost development and support costs. As a result, Tenet delivers highly effective IT for a cost that is far less than our peers, and this advantage is sustainable. In closing, Tenet Information Systems strives to support many different constituencies. Two of the most important are our patients, and such as Mrs. Ramirez, and our physicians, as represented by Dr. Cogan. The tools I have described today will continue to be expanded and refined to create the best possible experiences for these two important customers. And while every hospital and hospital system is somewhere on this journey toward effective deployment of information technology, it is important for you to know that Tenet is already a very mature user of information systems, and continues to make great progress with the highest-value opportunities in this industry. Thank you. And now I’ll turn it back to Trevor. (Applause) Trevor Fetter Well done. Thank you, Steve. Okay. Our next presenter is actually three presenters. I mentioned this morning in my remarks that we have quietly made some very fundamental and profound changes in our revenue cycle operation over the past five years. Steve Mooney, our Senior Vice President of Patient Financial Services, is going to lead the discussion over the next half-hour. He’s been with Tenet for 18 years and leads our
  • Tenet 2008 Investor Day Page 70 efforts in revenue cycle. Steve has led the reinvention of our collection efforts. He understands the importance of operational efficiency and innovation. And this team is leading our transformation towards a much more consumer-oriented way of operating in the revenue cycle from beginning to end. Steve. You have 30 minutes. You do not need to speak too fast. REVENUE CYCLE Stephen M. Mooney Senior Vice President, Patient Financial Services Thank you, Trevor. He’s a little concerned about my speaking speed at times. Well, good afternoon, everybody. I think we’re at the home stretch here. This is kind of a story that’s evolved over the last five years, and some of you have been around following us for several years; some of you have not. So kind of what I want to do, I want to kind of share a little bit about the last couple years; I want to go back to 2005 and 2007, a little bit of a flashback. And then I want to kind of talk about 2008 and beyond and where we’re going, and talk about what we’re doing to improve the pre-patient care experience and the collections and follow-up, and finally, the future of PFS. So stepping back to 2005, after 2005, we’re really focused on integrity and transparency. Trevor mentioned earlier we consolidated all our business offices around the country. We had about, roughly at that time 60-some; we’ve whittled it now down to a handful of seven locations we operate out around the country. And it was really around centralization, around scale¸ building large-scale operations and organizations, around data integrity, getting better information, and driving better business. intelligence. We’re one of the very few places in the organization where both financial and clinical data come together at one point. And we use that business intelligence to not only drive our operations but actually give it back to our client hospitals so they can drive their operations better. We then move forward to about a year ago. Well, a year ago we really started getting to the point where we really needed to optimize what we were doing in our locations. Jeff Nieman is with me on the stage today to talk about our optimizing processes. We do a regression analysis, (indiscernible) pay. So when do we call a patient? What do we actually do when we call that patient? Do we send a letter? Do we actually make a telephone call to get the most efficiency out of our overall operating model? We then talked about the patient-friendly and consumer focus. We had a patient-friendly letter we talked about. We know the revenue cycle was very, very difficult for people to understand in the marketplace. We wanted to make it more friendly to them, to help them understand their bills and what they’re actually receiving from us. That actually helped to also generate financial returns.
  • Tenet 2008 Investor Day Page 71 And then we talked about the shift in focus, moving from the back of the revenue cycle to the front of the revenue cycle. With all the business intelligence we’ve gained over the last several years, we’ve actually realized that a lot of things would be better at the front end, so we started shifting that focus. Not that we still didn’t pay attention to the backend, we’re still optimizing that; we started paying more attention to even the pre-patient care areas and the registration areas in the revenue cycle. Well, as we got to that point, we started maturing our vision. In our vision about the same time last year, we wanted to become a full-service revenue cycle service delivery organization that leads the industry in seven distinct ways. There’s a couple key words there. One is full service, looking not just at the back; we’re looking all the way from the pre-registration process, all the way through HIM, coding, to the backend of the revenue cycle. And also become a service delivery organization. We wanted to become service-centric in everything we did: service our patients, our physicians, our payers, and our hospitals. We were doing this in seven distinct ways, always around yield – something we never think about – more cash, faster, and do it with less cost. Business intelligence – we talked about that a second ago – one place where the financial and the clinical data come together. We wanted to utilize that internally with us, and also back to our hospitals. We have had drive innovation to healthcare industry revenue cycle. Innovation, healthcare, and industry revenue cycles – almost an oxymoron when you think about it. But we wanted to really drive both from the standpoint of the retail marketplaces, and also all the hospitality industry. What can we do that they’re doing? I always thought plagiarism must be a course they taught in college, because in order to think of brand- new things, sometimes we need to think of things other industries already have done and proven, and move into our industry in the revenue cycle process. Employer of choice – who was going to have the best employees and attract the best people – something we’re doing every single day. Provide superior service to our customers. And then the final two are around making the patient experience with the revenue cycles as integrated and transparent and easy to navigate as possible. We know how difficult it is; we need to make it better and easier for them to pay us for the services we provided. And following making our services for the patient and the physician a differentiator, something we didn’t really think about an awful lot about several years ago. Now, in our gut, it told us if we make a better patient experience and a better physician experience, we actually could help drive volumes in the organization. Well, although we liked our gut, we also like when it’s validated. And there was a study done on McKenzie in 2007, actually late last year, that actually did that for us, it validated this process. If you look here on the vertical axis, it talks about importance to physicians determining where to send patients. So you talk about Dr. Cogan, it’s like where is he going to send his patients when it ties to what he’s actually experienced with this patient? And then the
  • Tenet 2008 Investor Day Page 72 importance from patients for determining future visits and care. So Mrs. Ramirez, when she thinks about where to go to get her services, what’s important to her? When you cut across these two, you actually see there’s four areas that tie directly to the revenue cycle. One’s around convenience for the patient, one’s around ease of registration, ease of billing, and also being kept informed. So if we can do these things very, very well, and we can actually increase satisfaction scores, we believe it can make a differentiation by driving volumes into our hospitals. So what we’re going to do now, I’m actually going to turn the podium over to Ron Kelley. Ron’s going to kind of give you an update about our CPAS project which we talked about last year, kind of the results of that. He’s going to talk about what we’re doing from an innovation standpoint and what we’re doing to hopefully help satisfaction with both Dr. Cogan and also with Mrs. Ramirez. Ron. Ronald Kelley Senior Director, Revenue Assurance Thanks, Steve. What Steve talked about, Tenet today probably has more focus than ever before on the front of the revenue cycle, especially on our admitting and registration operations, which we refer to as Patient Access. And this focus on Patient Access in the front of the revenue cycle is helping making it easier for patients and physicians both to do business at Tenet, while at the same time having a very positive impact to us financially, especially in terms of increased cash collections, which you’ll see in just a minute. I want to spend a couple of minutes talking about and giving you some insight on four different major initiatives that are part of this focus on moving our attention to the front of the revenue cycle, starting with the CPAS, or the Center for Patient Access Services that we told you about last year. Now, in the case of Mrs. Ramirez, this is a picture of basically how the CPAS works today. As soon as her physician scheduled an appointment with the local Tenet hospital for her procedure, all of that data that the hospital gathered during scheduling on her appointment and upcoming surgery would have been transferred electronically to one of our two CPAS operation centers located in either St. Louis or the Dallas markets. The CPAS then starts to process that account for Mrs. Ramirez, making sure that we’ve completed her preregistration, verifying what her insurance benefits are, what types of managed care requirements may exist, such as you need to call and get a preauthorization or a precertification number. And then even sharing all of this insurance data back with Dr. Cogan, as Steve Brown mentioned earlier, through our Physician Portal, so that his office staff can make sure they have the most up-to-date insurance information, and both the physician and the hospital can bill appropriately for services.
  • Tenet 2008 Investor Day Page 73 Then the CPAS, in the second box here, starts to offer preservice financial counseling for Mrs. Ramirez. The last thing one of our patients want to be bombarded with are issues and dilemmas with insurance the morning when they’re about to go into surgery. So the CPAS financial counselors can call Mrs. Ramirez in advance of her appointment, and walk through and explain what her insurance benefits are. They can talk through what her managed care company will and won’t pay for, and even offer to set up payment arrangements or take a copay or deductible before service, so that the morning of her procedure, Mrs. Ramirez can walk through an expedited check-in process at the hospital. Now, about 70 percent of our hospitals today have been implemented on the CPAS, which we announced at last year’s Investor Conference, whose implementation was beginning at that time. And when we’ve gone through this implementation process over time, we’ve been very focused on looking at some specific patient access metrics to make sure that this new program and new operations center is being as effective as possible. And when you look at some of our hospitals that have been implemented on the CPAS versus those that have not yet gone through the installation, some of these metrics show some dramatic differences, such as the percentage of patients that we’re able to get preregistered before their date of service. This is a really important metric, because it helps serve as an indicator of how many patients we can move through the registration process faster. We’re also seeing a significant increase in the number of patients that we’re able to verify insurance and get a pre-authorization number for before the day of service. And this is a really important metric also, for a couple of reasons. One, it helps us make sure that we’re billing the claims to the right insurance company. It also helps us make sure that we avoid costly denial write-offs, or inconvenience the patient and physician if we have to reschedule because we don’t have a pre-auth number before that day of her service. And then the third metric you see here on this slide is one that shows the most dramatic improvement, and that’s in terms of point-of-service cash collections. If you look about 24 months ago, before the CPAS was even created, before we had turned on the CPAS for any of our hospitals, and compare the increase in the collection of patient liabilities like copays or coinsurance and deductibles, our CPAS hospitals are seeing more than double the rate of increase of collection on these patient liabilities than our non-CPAS hospitals who’ve yet to go through this process. Now, besides focusing on this new operations center, we’re also rolling out new tools that are used by both the CPAS and our registration staff inside the walls of the hospitals. The second initiative I want to talk about focuses on some of these tools, such as a quality assurance product that we also told you about at last year’s Investor Conference. We have now deployed nationwide an automated QA tool that immediately alerts registration staff if data that they’ve keyed into the system is potentially inaccurate. And you can see from looking at this chart some of the very specific and detailed accuracy metrics that we monitor. We’ve already seen some significant improvements in the quality of the data we’re capturing at registration. But besides just a quality improvement, this is also
  • Tenet 2008 Investor Day Page 74 showing benefits in other ways, such as helping us reduce our dedicated QA staff by over half since we turned on this new program. Some other tools that we’re also deploying are one, for example, called Care Pricer that helps us and our staff automatically calculate patient liability balances; it lets us give written estimates to patients. We’re also turning on another product called the ramp (phonetic) tool that helps us automatically process applications for assistance and helps us improve the cycle times of Medicaid or other government funding sources for some of our patients. Now, these tools are all used by our staff, but I’m really excited to tell you about tools that are starting to be used by some of our patients that both Bob Smith and Steve Brown alluded to earlier. I want to give you a little more commentary on a pilot that we’re working on right now under the name of a Rapid Registration Program. We’re actually deploying kiosks for patients’ self-serve check-in and electronic signature tools. Now, we started last December piloting in these three sites, and you saw this picture briefly from Steve Brown earlier of the three locations where we’re deployed these patients’ self-serve check-in kiosks in the South Florida area and our Houston market as well as one site here in the Dallas area. And we’ve seen some significant results initially by allowing patients to help test and use these products, including at one of our sites an 87 percent reduction in the amount of paper used during the registration process, while at the same time having a 30 percent reduction in cycle time, or the amount of time it takes the registration staff to key in demographic data for some of our patients. Now, if Mrs. Ramirez walked up and used one of these kiosks during our pilot, she’d experience about a three-minute check-in process, and she’d start off by being presented with a series of screens that you see here that are available in multiple languages and allow her to either swipe a driver’s license or credit card or key in some basic demographic data to authenticate her identity and help us make sure that she is who she says she is. Our patients are then walked through a very easy process where they can review their own demographic data and check in for services, and do other things like I mentioned earlier in terms of signing their consent forms and helping us reduce the amount of paperwork required during registration. This is a screen shot of an actual screen that a patient can see to actually walk through their registration and conditions of service and other required registration forms. And even though we’re still in a pilot mode right now, our initial estimates are that if we roll this out nationwide, we can reduce almost 20 million pieces of paper annually from across our hospitals in terms of registration paperwork alone. And I told Steve Mooney earlier that I think we need to call Al Gore and get him to help us quantify how many trees that’s actually saving in the process. Besides filling out registration forms and electronic signature, we’re also able to later this year have patients make payments directly at the kiosk. They’ll be able to swipe a credit card and pay for their copay or coinsurance, and even in the future set up payment plans. Now, we are finishing our pilot phase of this. We’re working with a couple of our vendor
  • Tenet 2008 Investor Day Page 75 partners and hope to be able to announce rollout plans further in the very near future for this real exciting technology being used at the front of the revenue cycle. And then finally, speaking of self-service, Steve Brown almost mentioned earlier our Online Bill Pay, which is now deployed nationwide across all of our hospitals. Patients can simply login and view all of their patient account balances, set up payment plans, or better yet, pay in full any outstanding balances that they owe to one of our Tenet hospitals. What’s really amazing about this is we just deployed it this year to all of our hospitals, and before we were able to start our marketing campaign and really publicize this but after we had flipped the switch on and the links were all active, we actually had patients start to use this before it was even published in any of our hospitals. So they found it on the Web and started making payments before we actually even turned it on and really publicized this new technology that’s not only a convenience to our patients, but it’s also another source of funding for us to bring more cash in the door. Stephen M. Mooney Thanks, Ron. Boy, I tell you, great results on the CPAS. I mean, we’re obviously getting some great innovation going. Ron’s not one to toot his own horn, but I kind of want to just kind of give you a sense of what this does to our satisfaction scores. I got an e-mail, I think an excerpt here, from one of our hospitals – it’s from our Diagnostic Imaging Center in West Boca – and the gentleman actually sent us an e-mail about the CPAS and said, quot;The West Boca Diagnostic Imaging Center is at a five-star status this month with the help of CPAS.quot; This is from scores that actually changed. There’s three questions on the PSMS score they get asked regarding the front-end registration area. One is the pre- visit phone call, whether it happened or not; the explanation of financial matters; and the courtesy of the caller. Their scores went from on the pre-visit from a 42.8 to an 81.5 percent. Explanation of financial matters went from a 55.1 percent to 81.8 percent. And the courtesy of the caller went from 32.3 to 81.3 percent. Phenomenal results. You can see once you start doing things in a centralized and a very consistent manner, it can make a very, very big difference to the organization. So great stuff, Ron. Next up is Jeff Nieman, who several of you probably saw last year that were here. Jeff talked about what we were doing in optimizing our processes. Jeff’s going to kind of go in and share with you what our results were from the segmentation work he did last year, and then where we’re at evolving that segmentation work into the future. So, Jeff. Jeffrey Nieman Vice President, PFS Operations Thanks, Steve. So as Steve mentioned, I’m going to talk a little bit about once we generate that visit from Mrs. Ramirez how we take that revenue and convert it into cash. I
  • Tenet 2008 Investor Day Page 76 talked a little bit last year and showed a slide that displayed what we were doing with aggregate patient cash for the company. So Trevor mentioned when he started out this morning that we had improved over the last year our patient collection rates across the board. This displays that same information just a little bit differently. So the blue area that you see on the chart here is our aggregate patient collections quarter-over-quarter from 2004 tracking us up to present; so it goes back about four years. What you see then is about an 11 percent total increase in cash, or about $9 million per quarter in patient cash that we’re collecting more today above what we were four years ago. Now, the truly impressive thing about that number is that during that same period of time – and there’s two things that are impressive. The first is that purple line that you see shows that we’ve actually decreased the net amount that we’ve billed to our patients. That’s stemming from really two different things. The first is our compact with the uninsured where we’re discounting uninsureds’ bills. The second is the hospitals that we’ve divested over that time. So despite the fact that we’re billing patients for less cash, we’ve maintained and actually slightly improved our overall cash collection position from patients. The second story that’s maybe a little harder to see at first glance is the two blue shapes. The darker blue in this graph shows the cash that we collect from patients before the bill is charged off or put in bad debt. The lighter blue is post-charge-off collections that take place inside of our collection agency. So during this same four-year time period, we’ve improved our pre-charge-off collections about 49 percent while decreasing 44 percent in the charge-offs. So there’s a huge shift that you see here from post-charge-off collections to pre-charge-off, accelerating cash for Tenet. So this is very interesting. We talked about segmentation; last year I showed you the 250-some leaves and picked out one leaf. So really, what has that done for us and where are we going next, and I’ll be able to share that with you today. I’m very excited to tell you about our new MicroSegmentation process. We’ve actually filed a patent for this process, because we believe it brings new technology and new business intelligence and decision-driven workflow to the industry that will really revolutionize how we collect on patient bills both for patients and for insurance companies. We’ve hired and retained a PhD-level statistician that helps us constantly refine and build these models to maximize the effectiveness of them. And we’ve created the technology now so that it’s a very flexible system. We can go in and on a daily basis, if we wanted to, change the tables and change the workflow decision making to drive how we collect and how we work. So it’s really become a system now that we can change on the fly. Well, what’s different between the old segmentation and this new MicroSegmentation? Well, MicroSegmentation’s much more complex. First of all, our old segmentation model, we looked at eight different data variables that were really focused around that particular patient. We looked at the patient’s credit score; we looked at some visit variables, such as did they come in through the ER, did they come in through a scheduled
  • Tenet 2008 Investor Day Page 77 visit, those types of things; and then some basic demographic information, are they married, and so forth. We’ve added some significant data elements to that. So we’ve added some new self-pay data elements. We now look at census bureau data on the block level. So we know, based on the block that that individual lives on, what’s the average income? What’s the average home value? What’s the size of the family, education level – those types of things which also help us predict the probability to pay. We’ve added additional credit report information, such as does this person have $5,000, $10,000 available in unused or untapped credit card limit that we can call them up and ask them to put the balance on. And then finally, we started looking back at their prior payment history with our hospital. So we know if the person’s paid us before, they’re obviously likely to pay us again or vice versa. And then we’ve added some additional insurance variables to the model, and I’ll talk at greater depth about how that’s helpful. So from a self-pay perspective, again, what does this do for us? And I showed a similar graph to this last year. What you see here is on the Y-axis, the percentage of accounts that are actually paying us, and the X-axis is the total population of accounts. So ideally, we want our curve to be as close to the upper left corner or quadrant as possible. We want to collect the most money from the fewest patients possible, because that’s how you get efficiency with self-pay patients, knowing that not all of them are going to pay you. So the 45-degree line is kind of a random distribution. The blue line there is our segmentation model, the model that’s been in place over the last four years. The green line is the lift that we’re getting with our new MicroSegmentation model and the 44 data points instead of the eight that we’re looking at. So what are some of the key takeaways from this? Well, on the lower left part of the curve, you see that we can almost perfectly predict the 30 percent of the population that is going to pay their bill. On the upper right side of the curve is the opposite. We can almost, again, perfectly predict with I believe 99 percent accuracy the 30 percent of the population that no matter what we do is not going to pay their bill. So how does this help us? Well, we can stop working about 60 percent of the accounts today aggressively, because we know that they’re either going to pay or not going to pay, and focus our efforts on the 40 percent in the middle of the graph, where our efforts, the number of times you call, the way that you approach the collection and so forth, may actually make a difference in driving that cash in the door. This is another slightly different view. This is our secondary bad debt collection model. So this is very old charged-off accounts that are kind of in a warehouse mode today where we’ve implemented the new MicroSegmentation model as well. Again, you see a nice shift up and left in the curve. And the takeaway here is that now, if you look at the blue line, the original segmentation, versus the green line, from the first 10 percent of the population, we’ve gone from collecting 25 percent of the cash in that 10 percent now to 45 percent of the cash from that 10 percent. So we’ve gotten about a 77 percent
  • Tenet 2008 Investor Day Page 78 improvement in the performance of our data and analytics and the application of that model. So that’s nice for self-pay. It’s gotten us a nice lift, and we project to continue to be able to sustain that moving forward. Where do we go next? Well, we think there are – and this is probably the more innovative and exciting piece of the model – we think there’s a lot of opportunity now to take what we learned from self-pay and to apply that to the insurance side of the process. So we believe, again, as we saw with self-pay, this will allow us to take resources and shift them truly on the accounts where we need attention to get them to pay, and accelerate insurance cash earlier into the cycle. So to give you a little bit of insight into that, this chart shows from the time that we drop a bill to a commercial or managed care payer how many days it takes them to pay. It’s just a raw number of accounts paying by day from bill drop, along the bottom of the line there. So you see most of the bills today pay somewhere between about 20 and 35 days. Well, in today’s world, we apply collection efforts kind of uniformly across this process. So the industry standard is every 14 days we pick up the phone and call the insurance company and say, “Why haven’t you paid our claim? What are you going to do about it? When are you going to pay it?” and so forth. Microsegmentation is going to help us get much more refined with that. So what we do today – I just had to put this in here, we’ve got the 1,000-leaf tree at the bottom – the new MicroSegmentation tree for insurance is actually a 4,200-leaf tree – much, much more sophisticated and complex than our self- pay modeling. And the reason is, there are many more variables; although the data elements aren’t as many, the number of variables are far greater. We look at 15 data elements, which are outlined in the box on the right-hand side here. And so every account goes in, we look at those 15 different data elements, and it drops the account into one of 4,200 different leaves on the tree that predicts for us each of those leaves. And some of them have the same answer, believe it or not, but it predicts for us exactly when we expect the insurance company to pay. Well, again, how is that helpful? What you see here is that in the data studies that we’ve done with the model – and we’re getting ready to put the model into place in a live production environment in about two weeks – but we’ve been tracking for about 45 days the effectiveness of the model on 22,000 insurance accounts. And what we’re seeing is that 70 percent of the time, we can predict very accurately the day that the insurance company is going to pay the bill without any intervention. So the key is, again, instead of following up on every single account that you saw in that graph every 14 days, now we can say 70 percent of the accounts in insurance we don’t need to follow up on. And we can accurately predict which insurance accounts those are, and determine when we need to follow up on the ones that pass that ideal timeline, and start getting those worked sooner, faster, and get the cash flow in the door, as well as then realigning the resources to do that. So we’re anticipating now that that realignment of resources, over an annualized basis, will save us about $3 million in labor costs.
  • Tenet 2008 Investor Day Page 79 So finally, what does that mean? Again, it means more cash, hopefully, in the door sooner than what we see it today. And it also has an application for Mrs. Ramirez. It means that she’s going to get an accurate bill sooner than she gets it today, and the sooner she gets the bill in the hand, with her insurance information resolved, with the amount that we’re asking her to pay, matched up to what her EOB tells her that she needs to pay, the more likely she is to pay the bill to us. Stephen M. Mooney Thanks, Jeff. I really think one of these days I’m going to start seeing bar curl (phonetic) on you. I’m not sure, but anyway, great stuff we’re seeing so far. Clearly, we’ve taken what has been kind of an art in certain areas and moving it into a scientific approach that we’re kind of driving the revenue cycle here and overall results. Well, we threw an awful lot at you, and I want to go back real quick and go through some of the initiatives and go back to Dr. Cogan and Mrs. Ramirez and talk about why these things we’re talking about are important to them. And as I flash on these, we talked about the CPAS a second ago, these are the areas I think we’re touching on – the ease of billing, being kept informed, convenience for the patient, ease of registration. Moving forward to the quality assurance, you can see it’s ease of billing. Then move forward to the pricing estimates and point-of-service collections. Then we talked about the registration process and what is that doing within the revenue cycle. And then Online Bill Pay, (indiscernible) around convenience and being kept informed. And finally, the segmentation- MicroSegmentation project. So we do believe that as we continue to move ahead with these initiatives, they’re actually going to derive higher-level satisfaction at both the physician and the patient level of the organization and drive volumes for our organization. Well, now going on to a thing that’s always important to us within the revenue cycle is cash. We always say cash is king; it’s very important to us in driving performance of the organization. Those of you who have followed my presentation in the last few years when I’ve done these, these are metrics that we have been tracking for the last five years, and around A/R days, managed care A/R greater than 180 days, and Medicare A/R greater than 60 days. From the point of transparency, trying to keep things very consistent, I wanted to share these three metrics with you again. You’ll see we’ve had some great improvement on A/R days, where you’ll see actually at the end of 2007 we had about 54 A/R days; this is patient A/R. That actually now has stayed at 54 days at the end of the first quarter. We need to do better. We have a commitment out there, we’re trying to drive two days out of our patient A/R between now and the end of 2008. Hopefully, from the things you just saw, from the initiatives, we’re going to drive it further, and I’ll talk about some more initiatives in a second.
  • Tenet 2008 Investor Day Page 80 Our Managed Care A/R, we’ve had some great improvements over the course of the last several years. And even as of the end of 2007, we saw an additional $30 million come out of our Managed Care AR greater than 180 days. Well, some of that’s been driving through our process enhancements we’ve been doing, as well as some Managed Care settlements. Probably those of you who have been following our earnings calls, we had a settlement in the fourth quarter of last year as well as a settlement in the first quarter of this year. We expect that to probably continue through 2008. And following Medicare A/R greater than 60, this is the metric that we actually saw probably a low (indiscernible) mark at the end of 2005 and into 2006 and into 2007, going on to the $13 to $15 million range. That’s actually now climbed back up now; it’s $34 million as of the end of the first quarter. A couple things going on here, primarily around the government. We had to change our actual fiscal intermediary that handles our Medicare claims for us, Mutual of Omaha that’s now WTS. They did a system enhancement which has actually slowed down some payments. Also, because of RAC audits, and some of the high-dollar audits we’re now seeing on our Medicare claims, those claims have to be reopened until they’re reprocessed. As a result, we’re actually seeing climbing in our aging. We’re watching this very closely. We have it labeled down to the actual civic hospital. We do believe this number’s going to come down, but I don’t know if it’s going to get down to the $13 and $15 million dollar number you had seen in previous years, just because of some of the changes now in the Medicare world. So what are we doing about revenue cycle running A/R days, driving overall cash collections, and patient performance? Well, there’s four primary areas. We talked about a couple of them quickly. One was around improving our point-of-service cash. Clearly, CPAS, we’ve seen some great results. You’ve seen the rollout from the 70 percent of the hospitals working with CPAS now to 100 percent, we expect that to gain even more ground. MicroSegmentation driving performance improvements across not only collecting cash quicker, collecting more cash by converting those resources, and actually spending less on doing that. Another big one was reduction in Discharged Not Final Coded. We can’t collect a claim until it gets coding and it actually gets out the door to the payer. We have inconsistencies across our hospitals right now where that number actually sits. We’re now driving down consistency across the entire organization, and we believe a substantial number, about $40 million, we can drive in additional cash by, again, this consistency across the organization. Payer collaboration – we worked very closely with Clint Hailey, who’s going to be up here speaking in a minute. We’re now working with major payers; we have five major payers we’re dealing with on a regular basis. Work on cost improvements – it costs them money to deal with claims as well. How do we do things more efficiently than we do them today to increase cycle time?
  • Tenet 2008 Investor Day Page 81 And finally, legal action where appropriate. Yes, we do have to assert our rights at times. Certain times we’re going to agree to disagree. As a result, we have to assert our legal rights. We have done that over the course of the last several quarters. We expect that to continue in 2008. I showed a slide a second ago, we have $217 million still sitting out there greater than 180 days – some of that resolved through normal processes, some that we’re going to have to go to litigation on. Now let’s talk about the future. Where are we going from here? We talked about the last five years, kind of what we established to consolidation, revenue cycle, an awful lot of business processes improvements, plenty of drive in innovations of the revenue cycle – I believe a best-in-class service industry. I believe there’s an opportunity within Tenet, and we believe we can actually drive this business forward in the third-party marketplace to actually servicing non-Tenet hospitals in the marketplace and creating new business for the organization. I’m showing this slide because like the revenue cycle outsourcing market space, we believe that’s going to evolve the same way the HRO, the human resources outsourcing space, and the ITO outsourcing space have evolved over the last 25 years. When you look back at the ITO space, look back over 25 years ago, it kind of looked like the revenue cycle outsourcing space does about five years ago. It was a situation where we had 100 supervisors out there in the market spaces doing niche solutions to individual providers – the situation we were in about five years ago. You’re now starting to see that evolve a little bit. You’re starting to see a lot more consolidation amongst the providers in the revenue cycle space. You’re starting to see hospitals now outsource revenue cycle completely, which they weren’t doing three years ago. So the market space is actually building, and we believe we have incredible competency within our organization to actually service the third-party marketplace and sell these services. You might ask how big a market is this? There’s about 6,500 hospitals in the United States. We take out some that we don’t think of our target market, around some of the VA hospitals and some of the military hospitals with a long, bureaucratic process for RFPs, we get to around 4,500 hospitals that have annual revenue of about $550 billion a year. Of that $550 billion a year, they spend somewhere 4 and 7 percent on revenue cycles; they spend about 1 to 2 percent on the patient access area; about another 1 to 2 percent on HIM and coding; they spend about 2 to 3 percent on the backend revenue cycle activities – for a total of somewhere between $20 and $38 billion a year on revenue cycle services. Well, just taking that conservatively, that 4 percent number, they’re spending about $20 billion a year. So we believe we can capture part of that marketplace. So we’re doing some of that slowly. Some of the divested hospitals we’ve recently divested, we’re starting to service those hospitals now. We didn’t do this years ago when we were divesting hospitals. Why? Because we just weren’t ready. We were still trying to make sure we had our operation internally where it needed to be. But now we think we’re in a place we can actually move that going forward.
  • Tenet 2008 Investor Day Page 82 We also had some preliminary discussions with non-Tenet hospitals, and those conversations have gone very well. So we believe over the course of the next several months you’re going to hear a lot more about where we’re moving in this particular area. With that, we’re clearly continuing on both patient and physician satisfaction. We’re driving performance improvement. We’re doing that through thought leadership as well as innovation. And finally, we believe there are additional opportunities in the organization, and the driver of all that is by delivering our services to the third-party marketplace. With that, my colleagues and I would like to thank you for your time and attention. I’d like to turn the podium back over to Trevor Fetter. Trevor. Trevor Fetter Okay. Our next speaker is Clint Hailey. We talked a lot today about Managed Care and our strategies in Managed Care. And as you probably know, Clint joined us two years ago from HCA, where he was in charge of Managed Care Strategies in the Texas Hospitals and Surgery Centers. He’s done a terrific job of enhancing our reputation with managed care companies, executing on our strategy that’s been careful about pricing and quality and leading this series of value improvements. And he’s very enthusiastic and very insightful about his work, and we’re just delighted to have Clint here. Take it away. MANAGED CARE Clint Hailey, J.D. Chief Managed Care Officer Thank you, Trevor. Good afternoon, everyone. It’s great to be here today to tell you about the progress that we’ve made in Managed Care over the last year since I spoke to you on Investor Day a year ago. I think it’s safe to say we’ve made a lot of progress – a lot of progress – in Managed Care at Tenet, and we have a lot more on the way. Before I talk about the progress and where we go from here though, I’d like to frame for you how our efforts affect physicians and patients – Dr. Cogan and Mrs. Ramirez. We’re removing barriers to access to our hospitals for physicians and patients, while simultaneously improving our rates. That’s really our objective, that’s our aim, and I’ve got a lot to tell you on that front here today. Okay. Last year when I presented at Investor Day, I told you about our three key focus areas in Managed Care, specifically, driving pricing improvement through our rate parity strategy; working with our hospital operators to focus on building commercial volumes; and improving our pricing strategically where we had highly disparate approaches and
  • Tenet 2008 Investor Day Page 83 methodologies amongst our hospitals and within hospitals on pricing approaches, and we’ve got some strategic initiatives to standardize those for all of our hospitals. So those are our three key focus areas. All the people in the Managed Care Department and the hospitals understand those, and I’m here to give you an update on our progress there. Okay. Let’s talk about pricing first. Last year I showed you a slide that gave you a snapshot view of pricing in one sample Tenet market out there. This is actually the same market – it will remain unnamed – but it’s very similar to a lot of Tenet markets. Frankly, the things you can observe here – it’s a little bit different chart than I showed you last year, but you can see the highly disparate rate levels, if you will. The pricing – the bubbles indicate how big the health plan is in a given market, and the gap or the space between those bubbles show you high to low what kind of pricing positions the health plans had in that given market. Well, that was a year ago. In 2008 you can see how we’ve narrowed that band. You can see that the health plan indicated by the light blue bubble moved up rather dramatically. It’s not drawn perfectly to scale, but you can see the gray bubble, which is the second- largest health plan in that market, moved up, closed the gap by more than half. And that’s typical. In most of our Managed Care deals, if you see us report a two-year deal, oftentimes that’s us right-sizing that market over a couple-year period of time. When we announce a four-year deal, similar there, right? All right. So that’s 2008. That’s kind of where we’re running in this one Tenet market. In 2009 where we anticipate being is finishing the job, if you will, from a rate parity perspective. And again, there are some markets that have four-year correction cycles, some that have three-year correction cycles; none, at this point, more than four-year correction cycles, but there are several that have longer cycles. So why is it that a health plan, or health plans in this case, gives us this kind of upside pricing? And it’s frankly not as difficult as it may seem. And that doesn’t mean that health plans are easy; it just means I think we’ve got a good story. We have a story of quality. We have a story of “must have” hospitals; you’ve heard that term today. And we’ve got great data, and when we provide them with data, the health plans, they know if they’re low-priced; we’re just validating for them what they already know when we show them how they compare to the other health plans. And that enables us, frankly, to move them up at greater clips than they otherwise would anticipate giving us. And when we’re forced to, we’ll also leverage our scale. We’ll leverage nationally, we’ll leverage our hospitals regionally, whatever it takes to get where we need to be from a pricing perspective. Okay. Also on the pricing front, moving away from rate parity, let’s talk about pay for performance. Dr. Newman showed you this slide. He characterized it as three health plans, because those three of those blue plans are WellPoint plans, and the other two are United and Independence Blue Cross. And so it’s three separate organizations, five health plans – five contracts. And these are the only five, other than the plan that Jeff Flocken referred to, that’s an employer-specific agreement out in Modesto that has pay-for- performance upside. But with these five agreements that we have here, it’s $35 to $40
  • Tenet 2008 Investor Day Page 84 million of upside over three years. So you have to divide those numbers by three to get a per-year upside potential. But that’s not really what’s important in my view though. What’s important here is that this is a clear trend, and I think you’re going to see – if we were to show you this chart in a year or two – you’re going to see every health plan, or most every health plan we have listed on this chart and the upside potential, from a financial perspective, being much greater. Okay. So how does this affect Mrs. Ramirez and Dr. Cogan? Well, with Mrs. Ramirez, she would probably view it positively if she knew – and she might not be able to connect all the dots – but if she knew that the outcome from her stay in one of our hospitals, and the service she received was linked directly to the compensation we receive. So this is the direct linkage quality from a financial perspective that affects Mrs. Ramirez. Okay. Let’s move on to volume. Last year I talked to you about some of the things we were doing on the volume front to help build managed commercial volume. We’ve obviously struggled in this front, as indicated by the chart here, but I remain optimistic and believe we’re positioned very nicely for commercial volume growth going forward. Some of our struggle has related to industry headwinds that Trevor talked about earlier. Part of it is just the timing of the phase-in of initiatives that we’ve got underway. For example, as you can see in this next slide, we have a tremendous number of hospitals that have been added to the networks of health plans over the last year; all of this activity’s happened in the last year. And if you add up the column that says Q207, that’s actually 107 situations where we were not participating in the networks of those health plans listed here. And I listed health plans that – if you look over to the right where it says zero, that’s the only ones I’ve listed. There are others out there that we still haven’t finished. That said, I fully expect us to be finished with this initiative by the end of the year. And you might ask yourself, well, how much volume is really at stake here? How much is this worth? Well, let me give you some evidence of how successful this can be. If you look at Aetna in the upper left-hand corner, when we moved from nine hospitals that were nonparticipating with Aetna to eight on July 1, 2007, that hospital that was added right there was Doctors Hospital of Modesto. And for the couple quarters prior to being added to the network, our hospital in Modesto was averaging eight to nine commercial admissions per quarter with Aetna. In the first quarter that they were in the network, Q307, the hospital had 18 Aetna admissions, or double the run rate that they had prior. In Q407, so continuing this sequential trend here, Q407 they had 32 admissions; so triple the volume that they had prior to joining the network. And finally, in Q108, our most recently reported quarter, they had 41 admissions, over four times the volume that they had prior to joining the network. And so you might say to yourself, you’re talking 30, 35 admissions, Clint. What is that – 107 non-par situations. All of them won’t deliver the same amount; that’s just an early indicator. That one is still in process, frankly. The ramp-up process takes about 12, 18 months, in my experience over the years watching this, and many or most of these non-
  • Tenet 2008 Investor Day Page 85 par situations went away January 1st of 2008, if you look at the progression of the numbers across the page. Okay. So what else are we doing on the volume building side? Similar to the story on hospital non-participating reduction efforts, we have a similar effort underway for our medical staff physicians. Now, most of these physicians, we don’t employ most of these physicians; these are just independent contractors on our medical staffs that have either not tried to get on managed care plans or they have had trouble getting on managed care plans. And so in our negotiations over the last year, we’ve tried to encourage the health plans as a condition for us adding our hospitals to the network and accepting what we accept to approach our medical staff physicians that they don’t have in our networks. As you can see, the progress that’s been made here is pretty dramatic, especially with the first three health plans listed there. And we’re doing this initiative with all of the health plans that we negotiate with. The reason that we have these five is because we pulled the data a year ago just for these five as a test case for whether or not this was even something worth pursuing. And over time, over the course of last year, we found that was, so we started pulling more health plans and engaging those health plans to work on this as well. So pretty dramatic progress there. The good thing about this, from a Dr. Cogan and Mrs. Ramirez story, is on both the hospital non-par reduction efforts and the physician non-par reduction efforts, Mrs. Ramirez, she’s going to like having more access. She’s got access to both the hospitals and the physicians at a greater number. As it relates to Dr. Cogan, Dr. Cogan now is not forced – when we add our hospital to the network – say the Modesto example with that – say he had some Aetna members that he needed to do surgery on or something like that, well, he was forced to go to a competing hospital, forced to split when he was with Aetna, or when he had Aetna patients and we didn’t have an Aetna contract. Now he can go to our hospital for that, so that’s helping Dr. Cogan, making his life easier there as relates to our hospital being in the network. Well, if Dr. Cogan wasn’t in the network – so going to this slide – Dr. Cogan’s not in the network. Before he might have approached Aetna about being in Aetna’s network, and Aetna just ignored him. And now, because of us prodding the health plans, you can see Aetna in particular went from 60 percent of our medical staff physicians to 87; a great story. So, Dr. Cogan, hopefully he views the value added, or views our efforts on his behalf as value-added. Okay. Last slide. Let’s talk about strategic pricing. Over the last year, we have become much more focused from a TGI perspective on helping our hospitals improve the price in their TGI service lines at a disproportionately high rate relative to the other service lines. Also, over the last five years, we had implant carve-out stop loss, trauma carve-outs, gave them away, and got them back in many situations. And that’s important because we need to put the money where we’re growing; we need to put money in services where we’re underfunded; and we need to take money out of services that are price sensitive and move
  • Tenet 2008 Investor Day Page 86 them into other services that are underfunded, so that the price-sensitive services are priced appropriately so they can promote volume building. Okay. That’s what I’ve got. Again, all the objectives are aimed at removing barriers for physicians and patients to access our facilities, and continuing to improve our pricing, contract rates through our rate parity strategy, pay for performance, supplementing that, and finally, commanding a pricing premium over time. Thank you. (Applause) Trevor Fetter I’m now going to introduce our final speaker, Biggs Porter. While I’m doing that, we’re going to have some handouts passed out and I’d like to say that this purpose of passing out these handouts is just so that you don’t have to scribble frantically a bunch of numbers as Biggs goes through a number of slides that are rich in data, shall we say, not so that you can flip ahead to the end, okay. Adam, I’m really talking to you on that one. It’s a pleasure to have Biggs with us and although he’s been with us for less than two years, he has brought a new and substantially improved level of analytical rigor and discipline to our decision making. It’s great to have an outside perspective. He’s been a key contributor to helping us develop our strategy. And I would just say on a personal level, to know Biggs is to love him; the more you know him, the more you love him, and we really do. Biggs, you’re a great colleague and it’s nice to have you closing out the day for us here. FINANCIAL SUMMARY Biggs Porter Chief Financial Officer I will close out the day with a Financial Summary. The hard copy’s been given to you because some of these slides will be used somewhat for reference purposes and I won’t be able to go through all the detail so it’s there for you later. As Trevor indicated, my messages are positive. The only substantive change to our outlook is on the year-end 2008 cash flow. So for those of you who are already to the back of the handout, you don’t need to spend too much time looking at all the detail; I’ll get you there. But, once again, the messages are positive. The first thing I’d say, first and foremost, is that we are making progress for a sustainable, profitable growth and positive free cash flow and this discussion is going to be about that. If you go back a year, there was a discussion about where’s the inflection point? I think now the inflection point is behind us and the real question is how steep is the slope? What’s the rate of the improvement that we’re going to experience from this point? And I’ll talk about that and give you some comfort.
  • Tenet 2008 Investor Day Page 87 We’ve had two quarters of improvement – fourth quarter last year, first quarter this year – where we’ve seen volume improvement. Plus we’ve had the two months of the second quarter, at 1.4 percent admissions growth for April and May. As Trevor mentioned earlier, that May has one less weekday; the raw number for May is a negative .8 percent but if you normalize it for the extra day, we would come out slightly positive. Likewise, if you look at paying admissions, you’re going to get roughly the same high statistics with paying admissions being at about the same level for two months and once again for May to normalize it probably being around breakeven to slightly positive. So we think once again two month basis, absolutely demonstrating growth, and we’re still on a path to solid admissions for the quarter for the year. We’re also on a very visible path to $1 billion of adjusted EBITDA in 2009. We talked about a bunch of the drivers there – or the drivers there – already today and expansion of physician base, the prudent investment we’ve been making over the last couple of years, the targeted growth initiative, which ensures that we’re targeting our resources in the right place and targeting our growth efforts in the right place, cost control, which has been excellent over the first portion of this year and was very good at the end of last year, and then the price enhancement that Clint just talked about, and we have a great view to further price enhancement after the future based upon a managed-care contract that’s already negotiated. Further to all that point, the question comes up occasionally as to what our ceiling is on profitability and on EBITDA margin, and there is no firm ceiling on EBITDA margin. To go back a year ago, two years ago, we had 11 to 13 percent target for an interim margin objective and said even at that point in time, we felt like we could exceed that over time and that there wasn’t a firm ceiling and we still feel that way. We’re also increasingly focused on balance sheet efficiency and free cash flow with $400 to $600 million in cash initiatives are still outstanding. This is the Broadlane Recapitalization or Sale, the MOB sale, and the disposition of other assets, excess land, or other assets, which didn’t yield an adequate return to us we’re looking to monetize. So we have increasing confidence that getting more of that in this year and that’s what’s driving some of our cash outlook improvement for the end of the year. We also talked about $310 million expected from the sale of USC. And all of this and certainly the first and foremost oriented towards improving return on invested capital as we go through time. So if we dispose of the assets, monetize the ones which don’t create an adequate yield to us, get good value for them, and have $400 to $600 million, obviously, that’s going to give us improved ROIC as we go forward. We also have abundant liquidity. We have the potential for over $1 billion in cash at 12/31/08 – I’ll walk you through that in a minute – and we also target being at or around breakeven free cash flow for 2009 and I’ll also show you the math on that if you haven’t already cheated and looked at it. Talking about some of the cost drivers or some of the value drivers. Focus first on cost – we’ve seen some of the latest charts already today. But as we closed out 2006 and entered
  • Tenet 2008 Investor Day Page 88 into the first quarter of 2007, we had higher cost growth than what we had planned on as a result of the volume losses we experienced. But over the course of 2007, we systematically started to take that cost out, culminating in the fourth quarter with a $60 million dollar annualized reduction in non-patient care staffing in the hospitals. That put us at 3.5 percent on normalized basis, cost growth year over year in the first quarter, which is very good and that declined further to 2.6 percent in the first quarter, which is really excellent. I think that demonstrates we can get the benefit of volume growth with 40 percent effected margin on volume growth we looked for, by good cost control, get a benefit of our fixed cost space. And secondly it also demonstrates that we are going to achieve the $100 million of run rate savings that we expected in 2008 over 2007 based on the actions already in place. On the pricing side. A little bit different chart than the one that Trevor showed earlier but the raw data underlying it the same that on outpatient, we’ve had improved outpatient pricing for several quarters, driven significantly by the ED charge capture initiative, but also by managed care negotiation and the (indiscernible) effects of those. On the inpatient side, it’s been increasing rate of growth associated with the managed care negotiations. In this case and in the case of pricing, we’ve eliminated the effect of cost-report adjustment so that it’s more or less pure pricing that is being shown on the charts so you can see more clearly the effect of the managed care price increases. Now, we do have further managed care price increases already negotiated – we have great visibility into that – for the rest of this year, for next year, and for beyond. That’s what is already indicated. There’s still some upside left to negotiate, but we feel very good about where we are from the standpoint of our visibility and the future pricing from a (indiscernible) standpoint. We also expect to have further left after the second quarter of ED charge capture and our initiatives there, however, it’s still fairly subjective as to how much that’s going to be and so at this point in time, we’ve not put it into our outlook. Government programs are expected to have a little more modest growth in the fourth quarter this year compared to last year because of the forecast to the facts that MSGRGs in the market adjustment and how they’re going to affect our specific hospitals. There’s still a ways to go here, but this point in time, it looks like they’ll be more modest in the fourth quarter this year. Now, we’ve left our outlook range for pricing conservative and our outlook relative to our first quarter actuals. Now, by saying it’s conservative, I think it’s implicit then that there’s an upside from that. We don’t see a lot of downside risks, but we do see upside risks with respective pricing at this point in time. Now, looking at uncompensated care. We have an improving trend in non-paying patients. Steady decline over time and the rate of growth here is a little different from
  • Tenet 2008 Investor Day Page 89 what you hear from others in the industry. And in fact it culminated in the first quarter of this year with it actually crossing over to negative. So in the first quarter of this year than in the first quarter of last year. That’s a very positive trend that reflects our efforts to reduce our exposure in this area. If you shift slightly to bad debt mitigation. Over the last two years, I’ll give you a summary of what I see has happened here. First of all, charity volumes have declined approximately six percent in 2007 over 2006 and you can see that in that prior slide. But at the same time, uninsured volumes rose by about nine percent so a little bit of a tradeoff there in terms of what was happening. Uninsured revenues increased by 21 percent. So clearly a higher rate of growth in revenues than in volumes driven by price increases. Now, bad debt expense, on the other hand, only increased by 13 percent on an annual basis year over year, so clearly there’s some mitigation occurring here between 21 percent growth of uninsured and only 13 percent growth in bad debt expense. That bad debt expense on a bottom line basis was driven by pricing, not by uninsured volume. That is my interpretation of the data and bad debt through the pricing really has no bottom-line effect; you have higher revenues, you have higher expense, it offsets at the bottom line. If you look at it from a volume effects standpoint, the volume effects are mitigated. They are mitigated through improved collection rates, improved aging, collection of older managed care accounts. All the things we talked about through the last year, two years, have been successful in mitigating the growth and volumes on uninsured patients. Now, 2006 and 2007, in terms only discreetly identified as mitigation, it was in excess of $20 million each year. Once again, the role of mitigation was greater than that through every month improving our collection and improving our aging, and improving our managed care performance. We’ve already reported $8 million, we pointed out $8 million dollars in the first quarter of 2008 and we think there’s plenty of opportunity to continue to improve bad debt performance in the mitigation of uninsured volumes as we go forward. Shifting to cash and looking at working capital for a moment. On accounts payable, this is excluding the CapEx element, or the Capital Expenditure related elements of accounts payable, we drifted down in our accounts payable days the first half of last year. We worked through a store that going in the third or fourth quarter by extending our payment terms back out to our nominal levels. We got some improvement there but we didn’t get to our full objective. We continued to work it in the first quarter of this year on a seasonal basis, got back up to a reasonable level, but by the time we get to the end of this year, one of the targets being at our accounts payable days being roughly equivalent or in the range of what they were Q4 of 2006. So looking for expansion of accounts payable to provide working capital – a cash flow from working capital – over the course of this year. On accounts receivable days, we’ve done a good job over time in reducing the days in receivables, but the end of last year, we didn’t fully hit our objectives and we’ve targeted to hit two days to reduce accounts receivable by the end of 2008 and some of the
  • Tenet 2008 Investor Day Page 90 objectives that Steve and his team talked about a few minutes ago will go to accomplish those. A little bit of specifics on the hospitals we’ve divested in California. The sales proceeds were not in the release. There’s been a lot of questions so we decided to go ahead and put it in today. But there was $41 million of proceeds related to the two hospitals that were in continuing operations; San Dimas and Garden Grove. The cash proceeds on Encino are not substantial; I’ll get to that in a second. On the two hospitals of continuing operations, there was a small EBITDA impact. Last year, EBITDA was only $5 million and was expected to grow only slightly this year. But more importantly, those hospitals had negative cash flow. In 2007, those two hospitals and an expectation of $21 million in seismic expenditures in the future, which no longer have to be incurred. On Encino, it was also – it was losing money on an EBITDA basis and on a cash flow basis at a rate of about $500,000 to $750,000 a month. So that loss, cash and value, has now been halted. In the aggregate for these hospitals, they were money losers. If you look at all three of them together, it kind of had negative EBITDA. Shifting to a summary of the 2008 outlook, this is a similar slide to what we’ve shown at the prior two conference calls. The first column represents the fourth quarter conference call when we first gave the outlook for 2008. The second column represents the first quarter column and the current column on the far right. At the first quarter call, we updated our outpatient visit outlook reducing it for a first quarter performance on visits, however, we offset that by increased pricing based on strength of our first quarter pricing and a managed care contract negotiations we’d already accomplished in our visibility into improved pricing going forward. So those offset and the other elements of the outlook remain the same. Now, in the current forecast column, we’re taking our year-end cash balance up from $200 to $300 million dollars to $850 to $1,150,000,000. So a substantial increase in the year-end outlook and I’ll walk you through that in just a moment. This next slide is the walk forward slide that we’ve been using to describe what gets us from EBITDA in 2007 to $850 million at the end of this year and $1 billion at the end of 2009 or for 2009. I don’t want to spend a lot of time on it. Certainly, if people aren’t familiar with it, I will be happy to take your questions offline or in subsequent visits but I’ll do a high level on it. We start out with $701 million EBITDA, actual results, or just EBITDA at the end of last year. We subtract from it cost-reported adjustments and some Medicare reductions, which are not going to recur. We’d add to that the effects of volume, the $61 million. We add to that the effects of pricings from a baseline pricing increased standpoint of 273. Then we add in the lift we expect this year on managed care price negotiations on that market parity move that Clint talked about a minute ago, $47 million. We have other
  • Tenet 2008 Investor Day Page 91 initiatives, this is a ED acuity or charge capture initiative and some other price-related initiatives yielding $33 million. Now, there is an inflation on cost, as well, so those back out $271 million but they’re significantly offset by the $100 million of cost reductions, which are the full run-rate of the actions we’ve already taken. To work down the EBITDA column, then it gets to the $850 million of EBITDA. All of that is substantially as it was before. Now, what has been added as a separate line at the bottom is an indication of the effect of the divestiture of the two California hospitals, Garden Grove and San Dimas, which I said did not yield a significant amount of EBITDA so for purposes of the outlooks, we’re saying basically it has no effect but it does reduce revenue, it does reduce costs, and that effectively will lift EBITDA margin although EBITDA itself remains unchanged. And all that description about 2008 basically carries over to the 2009 column. On cash, in 2008 walk forward, this walk forward starts from the December 31, 2007, ending cash number, beginning cash number for this year of 572. I think all this is roughly as it was laid out when we gave our outlook for the year except for where you get to the bottom of the chart where there’s $650 to $850 million of cash from initiatives and divestitures. And this reflects the increased confidence we have at being able to bring cash into this year from the $400 to $600 million initiatives plus the effect of the divestiture of USC plus the effects of the divestiture of the two California hospitals. Now, having said that, there will still be some cash from these initiatives still yet to be achieved in 2009, so we’re not changing the aggregate range of what we think is out there. Otherwise, the chart capital expenditures remained constant at $600, $650 million and adjusted cash provided by operating activities, $400 to $500. So the other elements have been left constant. The next chart, very similar, same underlying data sets, but it starts with a cash balance at March 31 and basically shows how you get from March 31 to 12/31/08 the same cash figures. In this case, once again, the elements will apply if you were to add first quarter results along with these, those on the prior chart. I do think what this chart shows rather effectively is the $210 to $235 million we expect to generate from working capital over the remaining three quarters of this year. And that’s driven by the fact that first quarter is always a big cash user for the company as we pay our incentive compensation, we pay the 401(k) match, and we have our normal burn down of accounts payables. Those would be expected to all reverse themselves over the remainder of this year and those liabilities be restored back up to a normal level at the end of this year plus some, as I said, to catch back up to the levels we would’ve had borderline with 2006. So substantial growth from accrued liability and payable standpoint. And then also in there is the two days of reduced accounts receivable that we expect to achieve by the end of the year. So that, if you will, is the big difference between looking at this on a three-quarter basis remainder of the year versus a full year on the prior chart.
  • Tenet 2008 Investor Day Page 92 Now, this chart, Reconciliation of 2008 Outlook to the Net Loss is really the obligatory Reg G reconciliation so I won’t spend a lot of time on it. I think the numbers will all align with numbers we’ve either exposed previously or appeared elsewhere on the charts. We certainly will answer questions on them later if you have them. Shifting to Capital Expenditures. This chart’s intended to give you a little bit of an insight into where the $600, $650 be designated for this year. If you start at the left, go over to the right, notionally it indicates what’s maybe more maintenance related to what’s more growth related, although all-in-all there’s growth pieces and maintenance pieces possibly mixed in at every element of this. And then top to bottom, it basically describes where the money is being spent from the standpoint of starting at the bottom, replacing the basic clinical equipment where we identify within each hospital what needs to be replaced each year, and we fund the hospitals to go do that. And then renovation, facility maintenance, routine equipment added in above that, major equipment, the cath labs, the CTs, etcetera. Clinical information systems technology above that. Other construction and expansion, and then finally hospital construction on the top. So as you can see and hear once again, a mix of maintenance and growth spending. I think it’s important to note that we are continuing to focus on both and continuing to build our assets for the future. From a note at the bottom, I think it’s very important for everybody to understand this particular point, that the State of California has changed the regulations with respect to seismic, and introduced a new hazardous testing standard for which we’ve replied for relief, and we have received relief at a number of our hospitals already. At this point in time we expect our total seismic requirement then to be reduced by as much as 50 percent from what we have previously disclosed. Now, there’s one or two big drivers in there. But having said that, some of this capital probably will be redeployed in the form of other spending as we would invest it in accordance with our policies and principles on investing for projects with good return that doesn’t necessarily all result in a net reduction in capital, but we certainly have greater flexibility now than we had under the prior regulations. There’s been a lot of conversation over the last several weeks regarding the items that we disclosed – what do they call them, special items or whatever – that we disclosed in our 10-Q and our earnings release. This chart basically depicts that those have, over time, been repeating in nature, at least on an annual basis. Let’s start with on cost report adjustments, there has been a steady trend of cost report adjustments over time. It did dissipate over the last two quarters, which we suggested it would, as we said that we expected those to decline going forward. However, on DSH payments related to Medicaid, there’s been a very steady trend of DSH payments over time, and so a fairly clear and fundamental element of our revenue stream. Flipping to the second set of items here, on bad debt reserves, we have periodic lead on an annual basis to reduce bad debt reserves associated with improved collections. So we have been able to demonstrate once again that we’ve been able to mitigate bad debt over the last two years through better collections. Now, compensation and benefits, there’s income one year and charge the next. Well, that just simply relates to the annual true-up
  • Tenet 2008 Investor Day Page 93 based upon what the results for the year have been relative to the accrual, so that can go either way at any point in time. This piece is Managed Care payers. We have had favorable resolution of these. We’ve disclosed them. They represent part of our bad debt mitigation, and certainly, there’s more room out there to continue to pursue older Managed Care accounts, so that can well continue into the future, and we would expect to have future benefits on those. Gains on sale, distribution through HMO are not like items, but nonetheless they do demonstrate that good things can happen, and may be different in nature but repeat over time. And then the negatives in the red at the bottom of the chart represents miscellaneous adjustments. Even the $18 million in the fourth quarter of 2006 was – I think it’s about five or six items making it up, so smaller items. But the bottom line is if you look at the bottom of the chart, you have $5 million, $11 million, $6 million, $11 million, $13 million, all favorable and all repeating on at least an annual basis. So we think that we’re disclosing information for everybody to clearly understand what’s driving our results, but think that it’s certainly not an indicator that these should be considered as one-time and non-recurring items; that’s a judgment that is independent of the disclosure. Okay. Moving to free cash flow for 2009, we start out with EBITDA of $1 billion, stock compensation expense we add back the $40 million, interest expense $360 million as a deduct – in this case that’s less than 2008’s interest expense, because we are projecting heavy to higher cash balance and higher interest income going into 2009. Working capital, expecting it to be a use of zero to $50 million. This is largely just a function of whether or not we’re able to fully mitigate the traditional growth in working capital that would occur with volume and pricing growth. If we’re able to mitigate that, then the number is zero; if we have normal growth, then it’d be more like $50 million usage of cash. CapEx, because of disposition of the hospitals, and because of the seismic relief, we’re now forecasting that free cash flow for 2009 would be more in the range of $550 to $600 million. And that would give us free cash flow before the Global settlement expenditure of a positive $30 to a positive $130 million. The Global settlement outlay for next year is $90 million, which would give us the bottom-line net free cash flow of a negative $60 to a positive $40. Now, if you look out beyond that, free cash flow would be expected to improve, just as would EBITDA from the Global settlement obligation being retired; that one would just affect the free cash flow. It gets retired in 2010, so after that point in time, there’s somewhat immediate lift from not having a recurring expenditure there. And then on the EBITDA side, we expect that 40 percent effective margin rate of volume growth to be earned so that we get succeeding lift in EBITDA and free cash flow from that source.
  • Tenet 2008 Investor Day Page 94 So just about wrapping this up, I’ll talk about risks and opportunities to that $850 million to $1 billion of EBITDA. If you look at the charts on the right, basically there’s two big value drivers here that in which these risks and opportunities largely relate. It’s the growth rate we’ve talked about. It’s been on a positive trajectory, and for the slope of that trajectory, the nature of the patients that walk through the door is a driver. Secondly, we have the 30 percent estimated fixed cost in our cost base, which is what gives us the effective 40 percent yield on volume growth as it comes in. So how those dynamics work together and our ability to achieve those cost efficiencies is critical to achieving our outlook. Now, the key strengths we demonstrated the first quarter were clearly volume growth going into the fourth quarter, the first quarter, and proceeding on the first two months of the second quarter. Commercial pricing, we have the strong negotiations that’s been showing up in the last few quarters’ results, and we understand from this point what our commercial pricing is going to be, the great visibility of this year and beyond, so very comfortable with what we’ve demonstrated there and what our expectations are. On cost control, we said excellent performance in the first quarter, good performance in the fourth quarter of last year, and we have the actions in place to manage that so long as we have the predictability of the volumes that I’ll talk about in a second. So from a key risk standpoint, going back to the point I was just making, the cost impact of uneven volume growth is a risk. We talked about this previously. If our volumes are erratic month to month, it is more difficult to manage our staffing against them. Or if we have a number of hospitals which are significantly underperforming while others are outperforming, then that becomes a more difficult environment to achieve that 40 percent effective variable margin on. Also, certainly, although we haven’t been seeing it, okay, in the business today, an accelerated growth with uninsured or a change in patient payment behavior is something that could negatively affect us. Now, we are watching for that, and we have not observed it, as we talked about. Our collection rates have not changed, and the growth rate has been declining in uninsured. But certainly if that were to change, that would be a risk. Now volume growth less than the 1-1/2 percent nominal level that we’ve assumed in the walk-forwards would, of course, also be a risk, but it’s also an opportunity to exceed that, and we’ll get to it in a second. From an opportunity standpoint, patient mix and payer mix – as I said, we’ve made reasonably conservative assumptions with respect to those and with respect to our pricing the remainder of this year. So therefore, it’s implicitly opportunity if we are able to outperform those conservative assumptions, and that’s certainly a possibility. Volume growth greater than 1-1/2 percent, obviously, an opportunity. And then improved collections. Steve talked about everything we’re doing to accelerate cash and to improve bad debt expense. We’ve already talked about the mitigation we’ve
  • Tenet 2008 Investor Day Page 95 accomplished so far. If we’re able to continue on that path and we don’t have the growth of the uninsured, then that represents net upside. So to summarize, we are making progress toward sustainable, profitable growth and positive free cash flow. We had two quarters plus two months in the second quarter that demonstrate that kind of improvement. We’re on a visible path to $1 billion of EBITDA 2009. That does not represent a ceiling; there is no implied ceiling. The longer-term EBITDA margin we think through volume growth will continue to get lift. We have abundant liquidity, officially more than $1 billion in cash at the end of this year, and we’re targeting being at approximately breakeven free cash flow in 2009. And we expect EBITDA and free cash flow expansion in 2010 and beyond as we bring in volumes and as the Global settlement’s retired. So with that, I will conclude my presentation, and Steve and Trevor will come back up for questions. (Applause) Trevor Fetter Thanks, Biggs. And also, this Q&A session, although we’re not going to invite them up to the stage, would include questions that you would like to direct to any of the after-lunch speakers. And give us a second here. Okay. Questions. Adam. Wait, well, you know, Adam’s gotten the first question every time. I’m sorry. Kemp. We’ll call on you second. Q&A Session Q. (Kemp Dolliver) And you were expecting an improvement in calling on me first? Quickly, you’ve referenced the USC situation several times, and even though it’s not – you haven’t announced a definitive agreement, from all the discussion today relative to the conference call and the initial announcement, it sounds like there is progress on a definitive agreement. Am I over-interpreting your presentations and body language, or is there something more you can say? A. (Mr. Fetter) I don’t think – I think the only other things that we could say is there’s always risk in any transaction. Although in this case, the university is highly motivated. This is something they have sought for several years. They’ve gone ahead and hired a head of – what is the position? A. (Dr. Newman) Provost. A. (Mr. Fetter) Vice provost for medical services. So this would include oversight of the medical school and the hospital campuses. They have an active search for a CEO for the hospital campuses. So, I mean, they’re
  • Tenet 2008 Investor Day Page 96 certainly serious, and I believe they have every intention of being first. Yes, Darren. Q. (Darren Lehrich) Thanks. So just going back to the cash initiative volume on the year-end cash balance, can you just give us a sense for what is in there in terms of asset sales? It would seem that that number doesn’t capture everything that you’ve announced thus far. So could you just give us a sense for what’s in there? And then I do have a second question I’ll just throw out there for Clint I guess, if he could just give us some commentary on how much of the Managed Care book has been priced and locked in for this year and for next year and if there’s any commentary at this point about 2010 as well. Thanks. A. (Mr. Fetter) Okay, Biggs. A. (Mr. Porter) In terms of what’s in the projection for this year, we’ve put a range on it. It’s $650 to $850 million from the basket of things which are out there. The total basket of things at this point would run from – you start with a $400 million minimum number, add $311 from USC, and you add $50 from the divested California hospitals. So the sum of that is approximately $750 million. And then the upper end of the range goes to a billion fifty, all right? Or it should be $950 million. The $650 to $850 is, without trying to clarify what pieces fit into what buckets, at the $850 million level, the big things would have to close out, and some things would linger on, some of the smaller things would carry on into the next year. On the $650 million level, there’s just a little room for one or more things sliding or for possibly not happening in full this year. So it’s not quite so scientific to say here’s the exact pieces that are in there. I don’t want to go there because it would start to create a great view as to value as well, which I don’t want to do. But we put the range, best judgment, at $650 to $850 for this year. Q. (Trevor Fetter) Then Clint, is your microphone still live? A. (Mr. Hailey) You asked a question about percentage of our portfolio that’s negotiated. I think on our last earnings call, we reported it was – and if I get it wrong, I defer to the earnings release. It was 84 percent, I believe, of the 2008 revenue base that’s – if it’s negotiated. And it was 68 percent for 2009. But we continue to make progress, and I anticipate those numbers will be better in the very near future. A. (Mr. Fetter) We had some questions back in the back here. Q. Thanks. Can you just talk about the size of the portfolio right now, any additional anticipated divestitures? And also, any update on the dispute with HCP and any resolution there?
  • Tenet 2008 Investor Day Page 97 A. (Mr. Fetter) I think we said on the – let me take the second part of that question first. On the litigation that we’ve had with the real estate investment trust, healthcare property investors, we have been making progress with them. I think we reported that at the last call. But obviously, we’ll make an announcement when we actually finish some sort of resolution with them. As for the question on divestitures, it’s not our intention to keep divesting hospitals. We’ve said that we’ll be active managers of our portfolios, but we’re always looking for opportunities to improve the strength of the portfolios. That could include acquisitions as well as divestitures. But with what we’ve done so far, I really think that we are virtually finished on the divestiture program. Sheryl. Q. (Sheryl Skolnick) Thanks very much. This is really just a proceeds question, but I’m going to ask it in a different way other than are you going to buy back your debt or are you going to keep the cash, so I’m going to ask it a little bit differently. The first Investor Day I remember going to – which was in your offices, okay, so the first one you did, two years ago, I guess, in August, July – you said, Trevor, I think something along the lines of, “Once we turn this business around, we’re going to run this company differently. The Street may be surprised by that.” I think you were referring to not going out and becoming a mass consolidation play, that after you get through turning it around and de-levering or do whatever it is you’re going to do, that you aren’t going to go back out and lever it up. So if that’s true, if you did believe that then, are you thoughts the same now? Would you use this as an opportunity, having this much cash on the balance sheet, to consider acquisitions should they be available, joint venture strategies should they be available? I know we talked about this a little bit more at lunch. Or is really the right thing to do to do lever? A. (Mr. Fetter) It’s a great question and a very clever way of asking it. And why don’t I give my perspective, and I’ll ask Biggs to add to that. I think a couple of years ago what was really different is that we stood out for having this exceptionally high degree of leverage in our industry. But at least two of the largest companies in our industry have now caught up to us in that. Three, I guess, actually, all through different means – acquisition, LBO, and recapitalization. Not that that’s something that we’re really comfortable with. I think we would ideally prefer to de-lever through improving operating performance, and we’ve talked about that before. I think it’s premature still to speculate about what we will do with the cash that we’re generating, because we have not yet generated it. As we’re sitting here today, I think we would just speak really hypothetical. But we are very mindful, and as I mentioned in introducing Biggs, he is particularly analytical and rigorous about what is the best thing to drive shareholder value, which is, after all, what we are charged with doing. Do you have anything to add to that?
  • Tenet 2008 Investor Day Page 98 A. (Mr. Porter) My first comment would be you could probably ask the question differently but you’ll probably get the same answer. I would agree with Trevor. I think first and foremost, obviously, we need to complete these transactions, bring the cash in, and then we’ll weigh over time what the best course of action with respect to capital structure or investment or otherwise. We are very disciplined; when we make investments, we want to make sure we do the right things: create shareholder value, and any other use of the funds will be the same consideration, what’s going to create the greatest amount of value. But there is certainly still a fair distance between now and the end of the year and having those funds, and so I think we’ll make that determination more as we get to that point. And there’s lots of distance between now and three and a half years from now, which is when the first of the debt maturity starts to get here. I mean, people think of it as 2011, it’s really the end of 2011, December of 2011, so it’s quite a long time from now. Q. (Indiscernible). A. (Mr. Fetter) Oh, yes, the follow-up question for those of you who couldn’t hear it is, is the thought of running the company differently, is it still okay to think about running this company for cash flows, for organic growth, and so forth – that’s what you’re talking about. Well, that’s one of the reasons we wanted to preview all these strategies – not preview, but explain all these strategies – and even preview some of the things that we’re doing differently going forward, as I think there is greater organic growth potential in the business than has been evidence certainly in the past, but also by transitioning to this more consumer-oriented model, and also by expanding into providing services, some of the services we provide to Tenet hospitals to hospitals outside of Tenet. I think that gives us incremental growth opportunities that are not capital intensive. That is running it in a different way. It’s also doing things differently than say the conventional wisdom in the industry. These are tough, challenging times in our industry, and it calls for different kinds of thinking, I think. It also calls for some of the traditional type of thinking. So the Physician Relationship Program is an example of something very traditional; it’s the basic blocking and tackling strategies, and frankly, I think something that we did not place a sufficient amount of evidence on in the early part of this story. Certainly 2003 and into 2004, we were very complacent about admissions; we didn’t see that problem occurring. As Marsha Powers pointed out, it got to a point in Florida where the physician attrition was quite bad before we really understood the problem and what needed to be done about it, and the solution that we are undertaking on that is a very conventional type of solution. Adam. Q. (Adam Feinstein) Yeah, sorry about that. Okay. Maybe just a couple of things to follow up, and I appreciate all of the detail, as always, Biggs. Just
  • Tenet 2008 Investor Day Page 99 on the Managed Care side, just looking at the incremental pricing, the $47 million, which is up from the $36 that you spoke about earlier this year, it seems like that’s where you have the most upside. I think you alluded to that, but certainly, just from looking at the numbers and seeing what you guys are reporting on the Managed Care pricing, it just seems like there’s a lot of upside opportunity there. So just curious if you can just elaborate, does that include all of the recent contracts that have been finalized? Does it make assumptions about contracts that have not been finalized? I know you have some bigger ones coming up in the coming months. I guess that would be my first question. A. (Mr. Porter) That number would substantially represent what we’ve already negotiated. There may be some upside off of that just from a pure negotiation standpoint, and from a performance standpoint, whether it’s the Managed Care contracts and the yield off of them or the yield off of the aggregate assumptions of patient mix and payer mix, there’s upside kind of spread between the Managed Care pricing, if you will, and the baseline price assumptions. So that’s where the upside opportunity is, more in the broad basket. Q. (Adam Feinstein) Is the Philadelphia contract included in there? A. (Mr. Porter)Excuse me? Q. (Adam Feinstein) The recent contract in Philadelphia, the Blue Cross? A. (Mr. Porter) Yes, it would be reflected. Q. (Adam Feinstein) Okay. All right. And then just on the free cash flow, to get to kind of that breakeven level in 2009, you had made some comments in one of your earlier presentations about bringing the DSOs down by about two days. A. (Mr. Porter) Right. Q. (Adam Feinstein) And then you wanted to get the payables back up to where they were previously, which would imply about a 10-day increase in payables. So is that embedded in the breakeven free cash flow for 2009 to see that? A. (Mr. Porter) That’s really the driver for this year. And next year the zero to $50 million on working capital would be a range which would be at the $50 million level of use attributable to working capital, say relatively status quo and not a lot of incremental beneficial performance on working capital. At the zero level, it would take some incremental beneficial performance on working capital, taking it beyond another day or two out
  • Tenet 2008 Investor Day Page 100 of receivables or getting other growth in accounts payable, or some other yield on working capital. Q. (Adam Feinstein) All right. Because yeah, it just – from when you think of the numbers that way, it’s a big spread between your – you know, you’re catching the float there with your payables, so clearly, it was there a few years ago, but just certainly I wanted to try to figure out in terms of just the probability of – A. (Mr. Porter) Yeah, well, I think that it is difficult to demonstrate the cyclical nature of accounts payable during the course of the year in accrued liabilities, but if you looked at the first quarter performance and you peered into it to its underlying drivers, it really did have the expansion of accounts payable today from both a negotiation standpoint and from a broader cash management standpoint. And we’ve talked about overdraft and accounts payable and getting all that to work. But it did work properly in the first quarter, so if we stay on a consistent path for the rest of the year and get the normal run-up in accounts payable that we would expect, and of course, we’ll have the accrued liabilities growing, then we are basically already on the path to achieving the accounts payable objective. Receivables, we still have to get a few days out. Q. (Adam Feinstein) And my final question, I promise. There was a slide much earlier today that’s talking about what you’re actually getting from a truly uninsured patient. I think it moved up from about 12 to 12.3 percent. So with everything that we talked about earlier – maybe it’s a question for Steven Mooney – just what’s the goal in terms of those ratios over the next three years in terms of what you expect to get from a true self-pay patient and then from a Managed Care patient, what you’re collection, the portion (indiscernible). Thank you. A. (Trevor Fetter) Great. Steve, did you hear that question? A. (Mr. Mooney) Adam, were you talking about more around the collection results we’re trying to get? Okay, because we’ve been getting around roughly around 12 percent from the self-pay patients and about 36 percent globally and about 65 percent from the uninsured patients. We expect actually to still see an uptick on the insured side of the patient. I mean, with the things we’re doing on the front end of the operation from the CPAS, a lot more from – you know, I’m trying to get patient collections before they actually get services for those patients, and we can, clearly. We expect that number to actually drive up. The uninsured side’s going to be a little more challenging for us to kind of guesstimate going forward. Some of the things Biggs talked about earlier was increasing charges. Well, clearly, if you’re increasing charges, which is near bottom-line effect with the bad debt expense and (indiscernible) to revenues, you’re going to actually might see a change in the recovery percentage on those
  • Tenet 2008 Investor Day Page 101 patients, and they’re actually seeing a change in the overall raw dollars in collections. So clearly, we’re still driving through our initiatives, segmentation, (indiscernible) what patients we’ll work, when to work them, what activities to work on those patients, we expect that to kind of mitigate some of that, but I’m not sure if we’re going to actually see a percentage increase on that side of the fence. Biggs, I don’t know if there’s anything else. A. (Mr. Porter) No. Thank you, Steve. A. (Mr. Fetter) All right. Shelly has a question over here. Q. Thanks. Shelley Gnall from Goldman Sachs. Just a couple more follow- ups on the revenue cycle initiative. Is it fair to think that most of the opportunity to improve the upfront cash collections at the point-of-service is on the outpatient, the ambulatory business? And is it right to think that real-time claims adjudication is a hindrance right now to improving sort of the cash collections from the inpatient? A. (Mr. Fetter) Did you hear that, Steve? A. (Mr. Mooney) The second part, there was a lot of commotion going on back here. Q. (Shelley Gnall) The second part was on real-time claims adjudication. It’s something I don’t think hospitals are able to offer yet. As far as better understanding what the patient really owes, a portion of their bill, before they actually leave the hospital, is that something that you guys are working on? Is that a future opportunity? A. (Mr. Mooney) Yes, and the second part, actually the Care Pricer which Ron talked about earlier on the presentation, we’re going to have rolled out through the course of 2008. That’s going to give us a much better view on what the patient actually owes on their portion. So we’re actually going to have the technology going in that says, okay, who has come in before, what’s a typical patient portion, going out and getting verification with the insurance company, and actually spotting that number pretty well, so we can actually ask for those dollars in advance, which we can’t do right now in all cases. So we expect to get much more refined as we go through 2008, and everybody will be rolled out on that program by 12-31-2008. On the other side of the coin, service collections, I mean, clearly, we expect the outpatient, we expect to get all those dollars in. And the inpatient side as well. Anytime we have a scheduled service, somebody we know is coming in our hospital, we expect to be able to get those point-of-service collections clearly before service is actually administered to those patients. One challenge we still have in our area is the emergency room operations, just because of EMTALA regulations, we can ask for no
  • Tenet 2008 Investor Day Page 102 financial obligation until such time as they’re actually stabilized, the patient. Then we can actually go into those at that point, sometimes when they’re leaving the hospital or before that activity happens. Q. (Shelley Gnall) Okay, great. Thanks. And then just one follow-up. Can you give us any sense of timing as far as when you might be willing to offer the revenue cycle services that were mentioned at the non-Tenet hospitals? A. (Trevor Fetter) Immediately. We’re actually offering services, and we have been for some period of time, to certain non-Tenet hospitals. We haven’t been aggressive about seeking that business; we’re capable of doing it as of today. Trevor Fetter All right. I think we have exhausted the questions here. We’ve also run right – I’d like to congratulate everybody for running on time today. Just a couple of closing thoughts. I was reflecting on something that Sheryl said right before lunch that, you know, is it true you’re no longer fighting fires and working on operations? And actually, I hope you’ve gotten a sense of that today. I think that accurately describes what we’re doing. We actually have time to do things like go to Washington tomorrow and try to influence government policy and go visit with large customers in the Managed Care area and things that really are key to driving the sustainable, profitable growth we talked about. We also are driving these innovations, and it’s very exciting. It’s something that’s different; it’s really motivating to our people. So over the next 12 months, I expect it’ll be a very good time for Tenet, and I look forward to seeing all of you again next year for our Investor Conference. Thanks for attending today. Thank you. (Applause) (End of Presentation)