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tenet healthcare EarningsPreparedRemarks

  1. 1. Tenet’s Q4 2007 Earnings Call Prepared Remarks February 26, 2008 Trevor Fetter, President and Chief Executive Officer Good morning everyone. This quarter we achieved a major milestone by generating positive growth in admissions. We also continued to demonstrate positive trends in several key areas and certain leading indicators have never looked stronger. I feel that the health and trajectory of this company is better than at any time in the recent past. This was the first time in nearly four years that we had positive admissions in a quarter. Because it was just slightly positive, I want to add some color to the statistic. First, we’ve had more consistent results among our regions than in past quarters, and we’ve continued to move more hospitals into positive admissions territory. Admissions in Florida stabilized significantly to just below breakeven, compared to the declines of more than 3 percent that we had been reporting in recent quarters. More importantly, the improving trend has accelerated into the first quarter of 2008, with same-hospital admissions up 2.3 percent through January. Florida admissions growth was positive for the first time since Q104, with an increase of more than 2 percent for the month. This upward trend has continued into February in both Florida and across the company. Even the trend in outpatient visits has improved. Same-hospital commercial managed care revenues increased by almost 9 percent despite a nearly 2 percent decline in commercial admissions. This is the single largest quarterly revenue increase we’ve reported in five years. We are positioned for further pricing strength as a result of the numerous managed care contracts we announced recently. In fact, these
  2. 2. contracts, with United, Cigna and Blue Cross of California represent a third of our total commercial managed care portfolio. And once again we kept the growth in controllable expenses on a unit of service basis at or below that reported by our peers. The innovations we’ve made in the revenue cycle continue to produce tangible results, despite the challenge represented by the continued double-digit increases in uninsured admissions. Because of these efforts, we were able to increase our collection rates from both insured and uninsured individuals. We also improved sharply in the non-financial metrics which we believe are important to our longer-term performance. These metrics are part of our Balanced Scorecard and incentive plan, and we believe they are leading indicators of our continued progress. We break the Balanced Scorecard into five areas, or pillars, which include quality, service, people, cost and growth. The first of our three non-financial metrics falls into our quality pillar. According to CMS’ most recently published Hospital Compare data, Tenet scores higher than any other investor- owned hospital company in CMS’ core measures, and we have the third highest score among the top 10 largest hospital systems in the country. We continue to hit all-time highs in our quality statistics even as CMS adds challenging new metrics to the mix. The next pillar is service. Our scores here improved as well, with physician satisfaction increasing 2 ½ percent over the prior year and patient satisfaction increasing nearly 1 percent. And in the people pillar, total employee turnover improved by more than 12 percent. Employee satisfaction improved nearly 4 percent. And although it’s not a balanced scorecard metric, I know you would find it interesting that our hospital CEO turnover in 2007 was just under 4 percent. This compares to a 20 percent turnover among our hospital CEOs in 2006. Q4 2007 Earnings Prepared Remarks Page 2 of 19
  3. 3. While we didn’t generate as much cash from working capital as we had planned, we did offset that at year-end with our other cash initiatives, which we expect will continue generating value going forward. Biggs will comment on those in a moment. Near the end of 2007, we engaged in a thorough business planning effort that resulted in the outlook we stated in this morning’s press release. This outlook envisions 2008 EBITDA in a range of $775 million to $850 million, and 2009 EBITDA of $1 billion or better. While I fully recognize the billion dollar objective represents a significant improvement from the EBITDA we generated in 2007, I believe we’ve set a clear path to achieving it. This will require strong and consistent performance on our part – capturing market share from competitors to meet our volume objectives, continuing to implement innovative techniques to offset the challenges on bad debt, and extending the progress that we’ve made in controlling costs and achieving enhanced pricing – but it is certainly within our reach. With that as an overview, let me turn the call over to our chief operating officer, Dr. Steve Newman, who will provide you with some commentary on what is driving our improvement in patient volumes. Steve… Stephen Newman, M.D., Chief Operating Officer SLIDE 6: Stephen L. Newman, M.D. – Chief Operating Officer Thanks, Trevor. And good morning, everyone. We made very gratifying progress in the fourth quarter that is continuing in the first quarter. In my opinion, our turnaround is accelerating and is increasingly evident in a number of areas. SLIDE 7: Momentum Building in 3 Key Areas To show you why I believe this, I’ll give you a flavor for our momentum in three key areas: volumes, pricing and its relationship to our quality initiatives, and our progress in expanding our medical staffs. I’ll also touch on the improvements we’re driving in Florida and the successes we’ve achieved in our new managed care contracts. Q4 2007 Earnings Prepared Remarks Page 3 of 19
  4. 4. SLIDE 8: Volume Growth Let’s start with volumes. Fourth-quarter same-hospital aggregate admissions increased a tenth of a percentage point over Q406. That’s the first positive quarter for admissions growth in almost four years. January’s in-patient admission growth was 2.3 percent and February has continued that trend, so I think it’s clear that our volumes are on an upward trajectory. The progress in the fourth quarter and in January is especially gratifying when you remember that we had a mild flu season until four weeks ago. It’s not our normal practice to disaggregate volume results – and we make no promise to do this on a regular basis – but I think some drill down this time will help you understand the underlying trends we’re seeing. In our key Florida market, fourth-quarter in-patient admissions were down just three tenths of a point – our best performance there since Q404. In Palm Beach County fourth-quarter admissions actually increased 80 basis points. Four of our five Palm Beach hospitals had positive year-over-year admissions growth. Additional evidence of our Florida recovery is demonstrated by January admissions being up more than 2 percent over January 2007. Our new Florida regional leader, Marsha Powers, has accelerated our physician recruitment, redirection and employment activities. We’re confident we’re finally on the road to sustainable growth in that important market. Now I can’t resist saying a few words about the remarkable and continuing progress of our Philadelphia market. Both Hahnemann University Hospital and St. Christopher’s Hospital for Children generated strong volume gains in the fourth quarter. As you know, we expected to gain volume at St. Chris because of the closure of Temple University Hospital for Children. But the gains at St. Chris have far exceeded what can be attributed just to that new affiliation. For the quarter, admissions at St. Chris were up 20 percent, which translates to an additional 498 admissions compared with the same quarter the year before. Also contributing to that success at St. Chris are our aggressive outreach activities beyond the five-county metro Philadelphia area as well as the addition of new high-end services like bone marrow transplantation. Q4 2007 Earnings Prepared Remarks Page 4 of 19
  5. 5. Meantime, Hahnemann’s admissions were up nearly one percent. We are continuing to work with Drexel University’s School of Medicine to grow our faculty practices at Hahnemann and St. Chris to benefit the educational, research and patient care missions of both organizations. We’re in the process of expanding our facilities in Philadelphia in anticipation of future growth, but we have sufficient capacity there today to handle the projected increases in volume over the near term. California was another bright spot in the quarter. Our California hospitals had an aggregate increase in admissions of 3.2 percent over the fourth quarter of 2006. We knew we’d see an improvement in the quarter because of our acquisition of the Stanislaus Behavioral Health Center in Modesto, but we also had noticeable increases in two of our other key California markets – the Palm Springs area and Orange County. For example, Fountain Valley was up 3.8 percent and Desert Regional increased admissions by 9 percent for the quarter. The Stanislaus facility added 263 admissions to the California aggregate total. But, even without that added volume, California admissions were up a solid 2.4 percent. We encountered some volume weakness in our Texas and Southern States markets, but we believe that softening will be temporary. One weak spot in the quarter was El Paso, but we have already seen improved admission volumes in early 2008. A major refurbishing project at another one of our Texas hospitals temporarily closed a number of our medical-surgical units there. In our Houston market, we’re about to pass the first anniversary of an aggressive new physician-owned competitor that hurt another of our hospitals. We expect that situation to normalize in the near future. The challenges in our Southern States region were very local in the fourth quarter. These resulted from slightly higher than expected physician attrition. We have taken swift action to accelerate our volume-building activities in both the Southern States and Texas markets. SLIDE 9: Volume Growth (Cont.) Q4 2007 Earnings Prepared Remarks Page 5 of 19
  6. 6. I’ll wrap up this discussion of volumes with brief comments on surgery volumes and commercial managed care admissions. Our total surgeries rose three-tenths of a point compared to Q406. Out-patient surgeries were up eight-tenths of a point while in-patient surgeries were down four-tenths of a point. This represents a dramatic improvement over the losses we had absorbed in total surgeries during prior quarters. As recently as the first half of 2007, quarterly declines in surgeries were 5 percent or more. Same-hospital commercial managed care admissions were down 1.8 percent in the fourth quarter. Our commercial managed care volume weakness was concentrated in Texas and the Southern States. Specifically, three hospitals located within our Texas market and Southern States region were responsible for 96 percent of this decrease company wide. As I just described a few moments ago, we expect that situation to stabilize in the near future. We continued to generate growth in many of the TGI service lines I highlighted in the third quarter. Commercial urologic surgery admissions were up 8.2 percent, ENT surgery was up 19 percent, orthopedic surgery was up 0.3 percent, neurosurgery was up 3.7 percent, and vascular surgery was up 16 percent for the fourth quarter. Meantime, obstetrics was down 2.7 percent, and open heart surgery was down nearly 14 percent or 68 procedures. Overall, I’d say the key takeaway about our latest admissions performance is that we are continuing to drive growth in the service lines we targeted as part of our Targeted Growth Initiative (TGI). As you recall, over the past three years through TGI we painstakingly identified the service lines with the best growth and profit potential at each of our hospitals. SLIDE 10: Pricing Gains . . . achieving our objectives Now let’s talk about pricing. We successfully renegotiated several of our major managed care contracts in the fourth quarter and the first six weeks of 2008. With the completion of new, multi-year contracts with United, Aetna, CIGNA and Blue Cross of California, we now have secured full network participation with every one of our major commercial payers for all of our hospitals, freestanding ambulatory surgery centers, diagnostic imaging centers and Q4 2007 Earnings Prepared Remarks Page 6 of 19
  7. 7. physician practices. These new contracts will also automatically add any new facilities or practices we might acquire during the term of the agreements. As you know, making sure that all our facilities are network providers has been a top priority of our managed care strategy, and I am pleased to tell you that we have now achieved that goal with our recently completed contracts. Our managed care pricing – including managed government programs – was up sharply with net inpatient revenue per admission increasing 9.4 percent and net outpatient revenue per visit up 9.0 percent in the fourth quarter. I believe that is a reflection of a number of focused efforts to align our Targeted Growth Initiative with our managed care strategy. Another of our managed care goals has been to qualify for as many managed care Centers of Excellence programs as possible. Additionally, in the last four months we have executed two contracts that actually provide potential incremental reimbursement to our hospitals for meeting mutually agreed upon clinical quality goals. SLIDE 11: Physician Relationships: Recruiting More Doctors Before I conclude, I want to share with you the latest results of our efforts to expand medical staffs at all our hospitals. In the fourth quarter, net of normal attrition, we added 241 new active staff physicians to our hospitals. For all of 2007, we added a net total of 1,086 physicians. As you know, this has been a critical priority for us. The success of our efforts in this area is especially gratifying for me, and it bodes well for the future growth of our hospitals. I truly believe that this progress in physician recruitment is a key indicator of our future volume growth. In the last year, we have increased the number of physicians with privileges to admit patients to our hospitals by almost 9 percent. It will take time for these new relationships to fully mature, but this growth represents a dramatic reversal of the erosion in our affiliated physician base that we experienced over the past several years. If I had to point to the one item that gives me the most optimism about our future at Tenet, this would be it. Q4 2007 Earnings Prepared Remarks Page 7 of 19
  8. 8. Through our Physician Relationship Program, we visited 4,720 physicians during the fourth quarter. Of those we visited, we saw an increase in admissions of 2.5 percent from physicians who already had staff privileges at our hospitals. We also visited 437 physicians who did not have privileges at our hospitals, and we expect many of them to apply for privileges as a result of our visits. This is an integral part of our strategy to gain market share in many of our fiercely competitive markets. To assist in these and all our volume-building efforts, during the fourth quarter we hired Lloyd Mencinger to lead our business development, marketing, advertising, physician recruitment and the Physicians Relationship program. Lloyd has years of experience in business development, working at both Baxter and Boston Scientific. SLIDE 12: Summary - Operations So, to conclude, the bottom line from my perspective is this: In the fourth quarter, we made progress in all the major drivers of performance in our business. We grew in-patient volumes for the first time in almost four years. We’ve continued to do that in 2008. From a pricing, quality and physician recruitment perspective, we continue to grow our channels for new business. Overall, I am very pleased by the trends I am seeing, and I am confident that we will continue to see improvements in 2008. With that, I will turn things over to Biggs Porter, our chief financial officer. Biggs? Biggs Porter, Chief Financial Officer Thank you, Steve, and good morning everyone. In the interest of time, I’m not going to repeat a lot of the numbers in our earnings release or 10-K. I’ll limit my comments to providing a relevant context for our disclosures. Q4 2007 Earnings Prepared Remarks Page 8 of 19
  9. 9. In the fourth quarter, we benefited from pricing, cost control, bad debt mitigation and stabilized volume. We finished the year with adjusted EBITDA in the middle of our last outlook and just within the outlook range we started out with last March. There were two unusual items in the quarter which largely offset each other. The first was a net charge of $12 million related to year-end accruals for compensation and benefits. This included adjustments to a predecessor company’s pension plan, union settlement costs in Florida, workers compensation adjustments and year-end incentive plan accruals. The other item is a favorable adjustment to our bad debt reserve of $19 million. This reserve is set through the use of an 18-month “look-back” on our collection history. As you know, our collection rates continue to show modest improvement across most customer segments. In recent quarters our results have often included cost report settlements, generally with favorable impact. The impact this quarter was effectively a net zero. With that brief analysis in mind, let me offer a few thoughts on the drivers that got us to those results. Steve has already covered volumes, so without detail, I will just reiterate how pleased we are to see aggregate positive growth, particularly considering the well advertised strong headwinds in the industry. I also want to note that our uninsured and charity volumes actually declined in January – so the positive 2.3 percent in admission growth Trevor referred to earlier will contribute to our bottom line. Now on to revenues, Fourth quarter same hospital revenues rose to $2.2 billion, an increase of 6 percent. Because of the essentially breakeven volume growth, this 6 percent revenue increase was principally due to pricing. Q4 2007 Earnings Prepared Remarks Page 9 of 19
  10. 10. Slide 18 on the web shows that we experienced solid progress in all our key pricing metrics. As a summary metric, normalized for cost report adjustments in 2006, net patient revenues per adjusted admission were up 4.9 percent. As a number of important contracts including Blue Cross of California and CIGNA were not effective until the first quarter of 2008, we anticipate additional pricing increases to contribute to our 2008 earnings. Substantially all of our existing contracts, including those negotiated in 2007, also have 2008 and 2009 escalators built in. We have good visibility into our managed care pricing for the next two years, because approximately 80 percent of our commercial rates for 2008 and over 60 percent for 2009 are already covered in signed contracts. Turning to costs, Same hospital controllable operating expense per adjusted patient day increased by 5.1 percent. As I mentioned a moment ago, this included a $12 million expense accrual for compensation and benefits expense. If we normalize for that accrual and the higher supplies expense on greater implant utilization, our expenses would have been in line with the expectations we had going into the quarter, with a number of lesser puts and takes among the other elements of our controllable costs. It is also important to note that we had a $13 million reduction in malpractice expense in the quarter. Based on the investment we have made in clinical quality, we are pleased to see this reduction. Unfortunately, we also had some poorer than expected cost performance in a few of our hospitals that lost volume in the quarter. We believe, as Steve mentioned, that both the volume and cost effects of that will reverse themselves. On Bad Debt, Q4 2007 Earnings Prepared Remarks Page 10 of 19
  11. 11. Same hospital uninsured admissions rose by 10 percent in the fourth quarter and revenues from the uninsured rose by 17.5 percent. Let me remind you, that this increase in uninsured revenue has been influenced by our recent efforts to improve the accuracy of acuity capture in our emergency departments. Any change in uninsured billings creates a parallel effect on bad debt expense. We estimate that $19 million of the $24 million in the uninsured revenue increase year over year is attributable to our efforts to improve the accuracy of acuity capture in our emergency departments and, to a much lesser degree, charge master increases. The corresponding $17 million bad debt increase has no effect on the bottom line since it is offset by revenue increases. Also, since we modified our ED charge capture process in the second quarter of 2007, we do not expect similar year-over-year increases in bad debt from ED charge capture in 2008. Growth in bad debt expense from higher uninsured admissions was approximately $5 million. Accordingly, the combined effect on bad debt of uninsured admission growth and pricing compared to last year is approximately $22 million dollars. Offsetting the adverse impact on bad debt expense from the growth in the uninsured has been continued progress on improving collections. Through focused effort, we have been successful in raising self-pay collection rates to 36 percent in the fourth quarter from 32 percent a year ago. Managed care collection rates also moved up to 98 percent in the fourth quarter, from 97 percent a year ago due to lower denials attributable to our previously discussed efforts to improve this area. These include greater Interqual screening, clearer contracting arrangements and better front-end processes. This improvement in collection experience led to the recording of the $19 million favorable adjustment to our bad debt reserves I mentioned at the beginning of my remarks. This compared to an $8 million favorable adjustment last year. Q4 2007 Earnings Prepared Remarks Page 11 of 19
  12. 12. In addition to the overall collection performance improvements, we also resolved older managed care accounts which had been heavily reserved. The favorable effect of this on bad debt expense was offset by what we see primarily as the seasonal aging of self-pay accounts. Like others in the industry, we typically experience a slowing of payments in the fourth quarter as our patients deal with year-end and holiday pressures on their household budgets. This is typically reversed by the end of the first quarter. So to summarize, same hospital bad debt expense grew over the prior year fourth quarter by $15 million. Uninsured volumes contributed $5 million to this increase, pricing contributed $17 million, and the net year-over-year reserve adjustment due to improved collections experience was a favorable offset of $10 million. Other variances, including the effects of the settlement of managed care disputes, netted to $3 million. While same hospital uninsured admissions and revenues were up over prior year fourth quarter, charity was down, making this another quarter in which there are opposing trends. Although not easily traced, we are optimistic that our strategies to emphasize favorable product lines and manage elective admissions and visits by uninsured are mitigations to what is a key risk in the industry. I emphasize the word “elective” in this regard. We also continue to drive on best practices in our billing and collection activities. I just did a fourth quarter year-over-year comparison on bad debts, but if you compare sequentially, it is important to note that uninsured revenues were actually down from the third quarter of this year. Turning to cash flow and capital expenditures, We ended the year with our cash balance within our expected range. In accomplishing that we didn’t do as well on cash from operations as we expected and spent slightly more capital, which should just be a matter of timing, but we continued to find other positive sources of cash on our balance sheet, which are more permanent in nature. As I will discuss in a moment, the variances to our expectations in the fourth quarter will turn to expectations of improved free cash flow and cash generated from operations in 2008. Q4 2007 Earnings Prepared Remarks Page 12 of 19
  13. 13. Cash from operations and free cash flow become sequentially more important metrics as we proceed through the next few years and approach the refinancing of our debt. In this respect you should consider 2007 as the year of heaviest investment for the company, with volumes starting to show the benefits, and with us well positioned to show improved earnings, cash flow and return on investment going forward. Capital expenditures in continuing operations were $300 million in the quarter. This figure was slightly above the higher end of our range we shared with you in our third quarter call and is roughly equivalent to the amount we spent last year. One of the influences on the higher spending in this year’s fourth quarter was that we wanted to make sure 2007 was our “catch up” year as we have previously projected. This leaves us with a manageable amount of carryover projects. On the Web we have included on Slide 23 a listing of the major capital projects of 2007. At this point I expect capital spending in 2008 to be little more front end loaded into the first and second quarters Also contributing to the higher level of capex in the fourth quarter, favorable weather has allowed us to accelerate the construction of our Sierra Providence East Medical Center in El Paso, which will now open a month earlier than we had expected. This generated $22 million in capex in the fourth quarter. We have also started the construction of a replacement hospital for our East Cooper facility outside of Charleston, South Carolina on which we spent $2 million in the fourth quarter. With respect to cash flow, Adjusted cash flow provided from continuing operations came in at $127 million for the fourth quarter and was lower than anticipated. The primary deviation was in working capital. We typically expect to see a more significant build-up in accounts payable and accrued liabilities at year-end than we saw this year. On the pure accounts payable side, we saw the increase we anticipated in the payment terms set up in the system. However, there was a $63 Q4 2007 Earnings Prepared Remarks Page 13 of 19
  14. 14. million decline in book overdrafts at December 2007 compared to 2006 which occurred due to the timing of our year-end check processing. This book overdraft should return to more normal levels in 2008, thus creating a source of cash flow in 2008. We also experienced a $31 million build up in Accounts Receivable. This is attributable to the effects of higher revenues and lower reserving for bad debts. This therefore doesn’t reflect bad performance. It in fact reflects improved collectability. However, we did not generate the net improvement we targeted in accounts receivable. In the fourth quarter of this year we did resolve a number of our older managed care receivables, but this was offset by the seasonal aging of self-pay accounts I referred to earlier. Other than that, we were overly optimistic in our ability to reduce accounts receivable over the course of one quarter. We believe it is going to take a few more quarters into 2008 to accomplish this reduction. Just to summarize the influences on 2007 in total, we had a net reduction in our book overdraft of $63 million, a reduction in accounts receivable credit balances of $54 million, and non-cash income related to prior year cost report adjustments of approximately $35 million. Not all of these affect cash from continuing operations dollar for dollar, but they did have a significant impact. We do not expect similar aggregate impact from these items in 2008. Accordingly, in 2008, as we indicated in the release, we anticipate having adjusted cash provided from operating activities of $400 to $500 million. This compares to $209 million in 2007 for an improvement in the range of $190 million to $290 million. Higher EBITDA is expected to contribute $75 to $150 million of this improvement. The remainder of the improvement includes a restoration of a more normal book overdraft position at year-end 2008, the two day reduction in accounts receivable we previously stated as an objective for the fourth quarter of 2007, and a reduction in the rate of pay down of credit balances. As I have said previously, we have engaged in a review to increase the efficiency of our balance sheet and correspondingly free up cash and increase return on invested capital. Let me now turn to the progress we achieved towards this end in the fourth quarter. We added $129 million in cash from these initiatives in 2007, of which $97 million was in the fourth Q4 2007 Earnings Prepared Remarks Page 14 of 19
  15. 15. quarter. At the corporate level, we monetized certain investments previously residing in our insurance subsidiaries and liquidated the cash surrender value of life insurance policies. We anticipate that continuing efforts to execute on this initiative can generate incremental cash ranging from $400 million to $600 million over the next 24 months. These include the sale of our medical office buildings, the recapitalization of Broadlane, in which we hold a 48% interest, and the sale or monetization of other excess land, buildings and other underutilized and inefficient assets. Since some of these items require marketing and price negotiation, I am not going to break them down into separate component values. Because the timing and value is within a broad range, at this time this additional cash is not in our 2008 year-end outlook. Before I turn to the outlook for 2008, I want to comment on the impairments we recorded in the quarter. They were much reduced over the prior year and included no impairments of goodwill. This is a sign that our turnaround is progressing and that our forecasts at the hospital level are for a broad based recovery. The single biggest reason for the impairments we recorded was the prospective reduction of Medicaid funding in Georgia and not attributable to our execution of our turn around strategies With respect to capital spending, For 2008 we expect Capital expenditures to be in the range of $600 to $650 million. This includes $82 million for new hospital construction, $32 million for seismic and American Disabilities Act requirements, and $25 million for Outpatient growth. Investors have often asked us to identify the portion of our capital expenditures which can be thought of as “maintenance” capex. Because of the many judgment calls necessary to distinguish maintenance capex from capital expenditures intended to grow the business, we have been reluctant to specify a number. By example, if we replace an old 4-slice CT scanner with a 64-slice scanner is that replacement or expansion? Intuitively, I would call that maintenance capital, although it may expand our capabilities. Our answer to date to the question of maintenance capital has been to point investors to the sum of depreciation, amortization and lease expense, net of implicit interest, which was approximately $500 Q4 2007 Earnings Prepared Remarks Page 15 of 19
  16. 16. million in 2007. Another way to look at this might be how much did we spend on our current core hospitals over the period 2003 to 2005 excluding physical expansion and new hospital construction. This was approximately $400 million per year over that period. If you look at the same statistic for the last five years, it was approximately $450 million. If you put all this together, then it would suggest an estimate of “maintenance capital” at approximately $400 to $500 million. Having said that, the lower end of the range, or $400 million, would likely not sustain our competitive position over a long term. Also, this excludes seismic and American Disability Act requirements as well as capital for expansion of the enterprise or in certain cases the construction or technology spending necessary to protect market share based on the action of our competitors. If you include those, it takes us up to the $600 to $650 million level we have spoken to as a reasonable level of average annual spend to meet regulatory requirements, and sustain and grow the enterprise. Moving to the Outlook, We have provided extensive detail with regard to our 2008 Outlook in this morning’s press release, so I won’t repeat all the line item detail here. The 2008 Outlook includes an expectation of adjusted EBITDA in the range of $775 to $850 million – or growth of 10 to 20 percent over the $701 million of adjusted EBITDA for 2007. Much of the “heavy lifting” necessary to achieve performance at this level has already been accomplished. I’m referring here to the contracts we recently signed with our major managed care payers, and the other pricing initiatives and cost efficiencies we implemented last year that will achieve full run rate in 2008. Having said that, there clearly also were some set backs, most notably the $60 million revenue loss from the Medicaid reductions in Georgia and Florida. We haven’t given a 2008 outlook previously, and over the course of last year, we maintained a 2009 outlook which, while having a lot of subjectivity, was between $1 and $1.1 billion of adjusted EBITDA. In the fourth quarter we updated the analysis indicating that of the $100 Q4 2007 Earnings Prepared Remarks Page 16 of 19
  17. 17. million of risk inherent in that range, $60 million had now been consumed by the Medicaid reductions I just referred to in Georgia and Florida. This still left us with a 2009 outlook of $1 billion or higher going into the detailed 2008 planning process. We have completed that process and continue to believe that the $1 billion or more of EBITDA in 2009 is achievable, although projecting two years out is by its nature very subjective. As I said, we have given a range of $775 to $850 million for EBITDA in 2008. Clearly, if we do not perform in the upper half of that range in 2008, reaching $1 billion or more in 2009 becomes a very significant challenge. As I said though, we continue to believe the objective is achievable, based on our progress in pricing, cost control and positive progress toward our volume objectives. If you ask me where the greatest areas of risk are that lead to the 2008 range or would cause us not to make the 2009 target, I would say the following two things stand out: • First: Although it seems we are turning the corner on volumes, this is, of course, a very subjective estimate. Equally important, mix between patients and payer categories can have a significant influence. To obtain $850 million in 2008 or $1 billion in 2009, we either need to have relatively stable mix overall and a limited increase in the percentage of uninsured and charity volumes combined, or we need to get offsetting yield from our bad debt initiatives. • Second: We need to have broad-based volume growth. If we achieve our aggregate volume objectives, but volumes remain volatile at the hospital level, it will remain difficult to capture the operating leverage of fixed cost absorption. Although we have seen a reduction in the variability of performance at the hospital level overall, if we have a significant number of hospitals that suffer volume decline in 2008, that will make the achievement of an aggregate 40 percent yield on volume growth more challenging. In slide 26 on the web, we have included a sample walk forward from 2007 actual results to 2008 at $850 million and 2009 at $1 billion of EBITDA. This is a sample walk forward, illustrating one path to our objective of $1 billion, or more, of adjusted EBITDA in 2009. It is not intended to give a series of spot estimates or line item guidance. There are certainly other Q4 2007 Earnings Prepared Remarks Page 17 of 19
  18. 18. combinations of line item performance which would produce the same, or higher or lower results. Having said that, this walk forward shows how the cost and price actions drive value relative to the more subjective estimates of volume and mix. In a nut shell, volumes drive approximately 33 percent of the necessary improvement in the walk forward from an adjusted 2007 starting point, with our cost and price actions providing the rest. You may recall that initiatives in place by the end of 2007 were estimated to achieve $118 million of improvement in 2008 and 2009 compared to that achieved in 2007. In the walk forward, the combined EBITDA effect of the initiatives now amount to $162 million, with $33 million related to revenue and $129 million related to cost. We have not assigned any value into the walk forward for our bad debt initiatives. We have thus implicitly assumed that the financial contribution of our bad debt initiatives will act to mitigate any potential increase in the uninsured or under-insured. The walk forward shows the effect of our cost and price actions and their effect on 2008 relative to 2007 in order to bridge to our prior disclosures of these initiatives. Since these are now imbedded in our recent actual results and in our budgets, subject primarily to just full run rate benefits, I will probably not keep isolating them going forward as they have become integral to our operations and are no longer discrete. This does not mean that we are not tracking execution of those plans and budgets. We are. In terms of the incremental lift from rate parity adjustments in managed care pricing we reflected in the walk forward, I can report that we are now negotiated on 100 percent of this in 2008 and 80 percent in 2009. There is still some potential additional pricing upside beyond those numbers. So, as I said before, we feel very confident about our pricing estimates, subject to any unforeseen regulatory change or mix changes. You will note that the walk forward starts by backing two amounts out from the $701 million 2007 adjusted EBITDA starting point: 1) the effect of the 2008 Georgia and Florida Medicaid reductions, and, conservatively, 2) $40 million of the 2007 prior year cost report income Q4 2007 Earnings Prepared Remarks Page 18 of 19
  19. 19. We may, in fact, have some effect of cost report adjustments in 2008 or 2009, but for now, we have taken $40 million of cost report adjustments out of the walk forward. By eliminating these two items at the start, our 2007 starting point for the walk-forward is a conservative $601 million. This conservative starting point of $601 million does make us more reliant upon volumes than in our prior walk forward. It now takes growth in volume-related revenues over the two year period in this sample walk forward, of approximately 2.2 percent in 2008 and 1.7 percent in 2009. Please remember that approximately 1 percent of this volume growth in 2008 is expected from the recent additions of Stanislaus and the closing of Temple Children’s hospital. Last year after we gave our 2006 results and 2007 outlook, some analysts tried to annualize our fourth quarter as a means of estimating what the next year should look like. I caution against this as it does not consider the effect of projected volume growth and the full run rate benefit of our 2007 initiatives. It also would not reflect that we have negotiated price increases on contracts beginning as early as January 1 of this year and that our annual wage increases are phased in later and are primarily in October, creating timing advantage between price and cost escalation. I know that was a lot to digest, so before we go to Q&A, I’d like to summarize briefly, • we showed real progress on volumes and pricing and took significant cost actions in the quarter, • we believe this progress is sustainable and that we can continue to leverage those actions to produce much improved results in 2008 and 2009, • and, we are driving on cash and return on invested capital as a key indicator of shareholder value growth. Let me now ask our operator to assemble the queue for questions. Q4 2007 Earnings Prepared Remarks Page 19 of 19