TENET INVESTOR DAY
June 3, 2008
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
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
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
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
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
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.
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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
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
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
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)
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
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.
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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
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
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
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
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’
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
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
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.
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
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.
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
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.
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
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
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
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.
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
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
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. 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
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,
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
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
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
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
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
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.
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
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
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
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
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
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
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
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
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
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
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
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
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
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
So it’s my pleasure to introduce Marsha Powers. Marsha.
FLORIDA REGIONAL REVIEW
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
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
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
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
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
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
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
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.
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
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
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
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
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
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
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
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
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
Ladies and gentlemen, please take your seats. The program will begin in a few moments.
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.
SUPPLY CHAIN MANAGEMENT
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®
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
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
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
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
I thank you for your attention today and I’ll turn it back over to Trevor.
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.
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
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
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
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
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
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
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
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)
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.
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
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.
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
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
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.
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
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-
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
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
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
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
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
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
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.
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.
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
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
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
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)
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.
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
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
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
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
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
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
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)
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
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
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.
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.
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
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
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.
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)