Q108 Conference Call Script
May 6, 2008
Thank you, operator, and good morning. Let me start by saying that I’m pleased with our results
for the first quarter. Tenet is performing more consistently than at any point in the recent past,
and it is becoming increasingly clear that the strategies we have in place are proving to be
We’ve now had two consecutive quarters of breakeven to slightly positive same-hospital
admissions growth, which is a great improvement over the consistent declines we saw from
2004 through most of 2007. Our same-hospital admissions were up of 1.0 percent for the
first quarter, with flu contributing only 20 basis points.
While we still have more work to do, this is the first quarter in a long time in which I would
say we’re pleased with our EBITDA performance. Same hospital adjusted EBITDA was up
23 percent to $239 million. And even though it’s still well below our industry peer
companies, our EBITDA margin rose 120 basis points year-over-year, to 9.9 percent,
continuing an upward trend of several quarters.
Thanks to our efforts across multiple initiatives, we now have a steady flow of physicians joining
our medical staffs. Going forward, we expect they will increase the number of patients they refer
to our hospitals.
Additionally, we are getting attractive pricing increases from large commercial managed care
customers. I believe this is a result of our multi-year efforts to raise our standards for clinical
quality, improve the reputations of our hospitals and Tenet as a company, and employ better-
informed contracting strategies.
The strong cost discipline we’ve demonstrated in the past few years continued in the first
quarter. One of the good things about our business is the operating leverage that you can
generate through modest increases in volume when combined with good cost control. This
operating leverage helped us deliver good performance in the unit cost metrics that we
reported this morning.
And though we saw a modest increase in bad debt expense, even here we made real progress.
The rate of growth in uninsured admissions slowed to 5.4 percent from the more challenging
7 percent to 10 percent growth rates we reported last year. Total uninsured and charity
admissions actually declined by 1.2 percent in the quarter.
Those of you who follow the large managed care companies are well aware that enrollment
trends across the managed care industry are flat. That trend, along with enrollment declines in
the rental networks, explains about one-third of the declines in commercial managed care
volumes that we experienced in the quarter. Also, over half of the loss in commercial volumes
comes from just three hospitals.
Steve Newman has some very interesting insights into commercial volume growth coming out of
our Targeted Growth Initiative which he will share with you in a few minutes.
EBITDA grew more than 20 percent in the quarter versus Q107. This stronger than anticipated
performance was driven by pricing and cost control. We expect continued good performance on
commercial pricing and costs. So, if we can close the remaining gap on volumes, particularly the
mix of volumes, we are well-positioned to meet our earnings objectives for the year. Looking to
our 2009 objective, we need to build upon our rate of volume growth and maintain the pricing
and cost discipline I just spoke about.
I’m pleased to report that our volume growth was strong in April, with same-hospital admissions
up by 3.7 percent and outpatient visits up by 2.8 percent. Because there was a lot of noise in Q1
this year due to leap year and Easter, we thought you’d find some year-to-date same-hospital
statistics to be useful. For the first four months, same-hospital inpatient admissions are up 1.6
percent, commercial is down 2.6 percent, charity and uninsured are up 1.3 percent and outpatient
visits are down 0.1 percent.
I want to close by commenting on two other items:
Earlier this month, we announced that we had signed a non-binding letter of intent to sell
USC University Hospital and USC Norris Cancer Hospital to the University of Southern
If this goes through, it will settle all litigation between the parties. Though we would have
preferred to retain these hospitals, the continuation of the litigation was beginning, in my
opinion, to do irreparable harm. We disclosed in the 10-Q certain financial information
about the hospitals and the sale transaction, but the key take-away is that the sale price will
be equal to net book value at closing.
As a point of reference, the net book value was $311 million at March 31, 2008. Last year
the hospitals generated EBITDA, excluding corporate overhead and non-recurring items, of
approximately $25 million. A normal level of capital expenditures is at least $10 million per
Finally, let me remind everyone that we have our annual Investor Day scheduled for four
weeks from today in Dallas. It will be available via live webcast. This full day of
presentations will give us the opportunity to discuss, in detail, our operating strategies,
progress, and growth initiatives.
With that, let me turn the floor over to Tenet’s chief operating officer, Dr. Steve Newman, to
provide further detail on our activities during the quarter.
Stephen Newman, M.D.
Q108 Conference Call Script
May 6, 2008
Thank you, Trevor, and good morning everyone.
Let me start by reviewing our progress on medical staff development and relationship building.
Physician relations represents an appropriate starting point, because it is the cornerstone of our
business, and physicians are incredibly influential in determining our market share and growth.
We continue to place significant effort into our Physician Relationship Program, or PRP.
Through the PRP initiative we made 13,158 calls on 6,764 physicians in the first quarter. The
PRP targeted physicians with existing active staff privileges increased their admissions to our
facilities by 5.7 percent in the first quarter of 2008 compared to their admissions in Q107. This
is our best quarterly performance since we launched the PRP program in late 2005.
We also called on 497 unaffiliated physicians in the first quarter. This group of almost 500
physicians represents practitioners currently lacking admitting privileges at any of our hospitals.
This effort is aimed at redirecting physicians already in our service areas. This creates a virtual
pipeline for future expansion of our medical staffs. Many of the calls made in prior time periods
resulted in new physicians joining our staffs and contributed to the admissions we achieved in
the first quarter. We added 178 active medical staff in the first quarter net of attrition. When
added to the previously reported 2007 expansion of our active medical staff, this aggregates to a
10.3 percent growth of our hospitals’ medical staffs since the beginning of 2007.
I want to highlight some of the enhancements we are making in the PRP program. We are
extending the numbers of staff in our hospitals joining the PRP teams and educating them
through our expanded training curriculum. We are also launching a customized education
program for our hospital-based physician recruiters.
Our overall admissions grew 1.0 percent in the quarter compared to admissions in the first
quarter of 2007. While we had a decline in aggregate commercial managed care admissions, the
aggregate number of negative 3.7 percent doesn’t tell the whole story. You will recall that two
years ago we began implementing our Targeted Growth Initiative, or TGI. Take a look at the
data on slide 15.
As you’re turning to slide 15, I need to make an important point about TGI. While we’re
showing you how we’re doing in attracting commercial patients to our hospitals in the targeted
service lines, a number of service lines which are heavily skewed towards commercial patients
were de-emphasized by TGI. These de-emphasized service lines often include neonatology,
obstetrics and selected outpatient services.
At the same time, TGI often emphasizes services that apply principally to the senior population.
For example, our resurgence in Florida, which made a key contribution to our profitability in the
quarter, was heavily Medicare-driven.
The point to keep in mind is that Targeted Growth means exactly that. We are targeting the
service lines with the greatest potential for growth in volumes and profitability. And, as slide 15
shows, for commercial managed care, the targeted service lines performed better than the
aggregate commercial volumes.
Let’s look at the eight service lines most commonly targeted for growth in our hospitals. Seven
of the eight service lines showed significant growth in comparison to volume in Q107. The
range is from up 0.4 percent to up 9.5 percent. The one service line that was down out of the
eight, as we’ve mentioned on other quarterly calls, was cardiovascular services, also known as
Cath/EP, which was down 12.9 percent. The emergence of local competitors has caused us to
lose market share in these services, but we have implemented plans to stabilize and subsequently
recapture market share in this service line.
Moving our perspective from targeted service lines to individual hospitals, commercial volume
declines were very concentrated with more than half the decline of 1,520 commercial admissions
occurring in just three hospitals. Each of these hospitals was confronting unique local issues.
These issues are being methodically addressed, and we believe a number of them can be reversed
within a reasonably short time frame. In fact, in April we saw commercial admissions return to
flat in these three hospitals.
I would be remiss if I failed to spend just a few minutes highlighting the remarkable progress we
continue to achieve in Florida. Our 10 Florida hospitals had aggregate admission growth of 1.1
percent in Q108 over Q107. This is the best performance turned in by our Florida operations
since Q104. We have continued to succeed in reducing out migration from our network in
neonatology, cancer care and advanced cardiac services. We are regionalizing certain services
like advanced neuorointerventional activities at Delray Medical Center while several of our other
Florida centers are obtaining Primary Stroke Center designations and will act as referral sources
to Delray for the most advanced care. I should also note that commercial managed care open
heart procedures in Florida increased 14 cases or 17.7 percent compared to the first quarter of
2007. This is our first market share gain in Florida commercial open heart procedures since
Finally, I want to offer some additional color on April volumes. We were very pleased to see
April admissions growth of 3.7 percent over April 2007. Even if we normalize for the extra
weekday in April 2008 versus April 2007, this would have to be characterized as a very strong
performance. Importantly, all five of our regions achieved volume growth in April in a broad-
based resurgence over a softer March. And, importantly, commercial admissions grew by a very
encouraging 0.9 percent.
Let’s spend a few minutes looking at our outpatient business. We were particularly disappointed
with the decline of 1.1 percent in outpatient visits and a 2.1 percent decline from commercial
payers in the face of an extra day for Leap Year. The majority of losses was in imaging and
referred laboratory studies. While overall outpatient surgeries were down 1.7 percent, I am
pleased to report the volume of outpatient surgery in our freestanding centers increased 11.7
percent in the first quarter.
With the moderation of outpatient losses over the last six quarters, we are becoming more
aggressive in implementing initiatives to recapture market share. To do so, we have expanded
the staff in our outpatient services group and continue to make selective and opportunistic
acquisitions in both ambulatory surgery centers and diagnostic imaging centers. This is a highly
competitive business, but we believe we can win the business with service excellence, quality
outcomes, operating efficiency and industry-leading throughput times which patients and
physicians increasingly demand. To this end, we are implementing centralized scheduling on a
number of campuses, giving physicians and their critically important office staffs, the ability to
do one-stop scheduling. We are also replicating techniques which are driving success in our
freestanding centers in our hospital-based outpatient surgery units.
Before leaving the outpatient discussion it is noteworthy that April outpatient volumes were up
2.8 percent compared to April 2007. Additionally this volume improvement was broad based
with 4 out of the 5 regions in the company showing gains for the month.
Turning to pricing, we achieved very solid improvements in the quarter. This is the tangible
result of the steady stream of new agreements successfully negotiated and announced since last
These enhancements include not only the normal inflationary resets, but also reflect significant
progress towards our objective of closing the pricing gap relative to competitors to achieve rate
parity. There are still isolated instances where we have yet to attain rate parity. While we have
negotiated the great majority of our contracts in the near-term, potential incremental gains
remain in the intermediate to long-term.
Our managed care team carefully monitors our commercial volume activity in each of our
markets. It has been interesting to observe that we have experienced good growth in commercial
volumes in many of the same markets where we have seen significant pricing gains. A
significant percentage of our pricing gains have simply closed the previously existing gap
between Tenet’s commercial rates and that of our key competitors. Since our rates have only
just now caught up to our competitors, pricing has not been a deterrent to commercial volume
Last week we reached a memorandum of understanding with Independence Blue Cross for a new
multi-year contract which would give all of their subscribers in the Philadelphia area access to
our two hospitals, Hahnemann University Hospital and St Christopher’s Hospital for Children.
This new agreement will also cover our faculty practice physicians and all of our outpatient
facilities. We are also pleased that this new agreement includes provisions for our hospitals to
receive incremental payments for reaching mutually agreed upon quality goals. While the total
dollar amount of these potential quality payments is small relative to the size of the contract, this
formal recognition of quality differentials strengthens what we see as an important precedent in
the industry. Our strategy is to position ourselves for success in a pay for performance
We have also made substantial progress in improving the cost structure of our hospitals,
outpatient facilities and support services. Productivity, as measured by FTEs per adjusted
average daily census, improved 1.2 percent in the quarter compared to Q107. Same-hospital
contract labor expense per adjusted patient day was down 10.7 percent. Part of this was due to
an 18 percent reduction in registered nurse turnover in the quarter. Same-hospital supply costs
for the quarter were also well-controlled increasing by just 3.9 percent per adjusted patient day.
This is excellent supply cost containment in view of a 1.2 percent increase in orthopedic,
neurosurgical and general surgery procedures, which required the use of implantable devices.
While we made significant improvements in overall costs during the quarter we continue the roll
out new and improved tools for our managers to help them track productivity and improve
throughput and efficiency through process redesign. We are also expanding our efforts to
standardize many high cost implants.
In summary, our strategies to grow our admissions, our medical staffs, and to control our costs
are working. This, combined with improved pricing through managed care negotiation and TGI
focus, delivered significant bottom line improvement.
With that let me turn the floor over to our chief financial officer Biggs Porter for his review.
Q108 Conference Call Script
May 6, 2008
Thank you, Steve, and good morning everyone.
Trevor and Steve have already done a good summary, so I will focus more detail on some of the
financial elements in the quarter. Before I do, I will note that our first quarter adjusted EBITDA
of $234 million keeps us well on a path to achieve our outlook for $775 to $850 million in
adjusted EBITDA for the year.
On a same-hospital basis, adjusted EBITDA increased to $239 million, an increase of 23 percent.
It was a relatively straight forward quarter, but there are a few items I will mention:
1. Favorable cost report settlements, added $2 million pre-tax, down from the $12 million
recorded in the first quarter of 2007.
2. There was $8 million of bad debt mitigation resulting from the settlement of long overdue
disputed managed care accounts.
3. We recorded $6 million in funding from Georgia Medicaid, $4 million of which is
retroactive to last year, as the state reversed approximately $7 million of its funding cuts
we disclosed last year.
4. We recorded $6 million in distributions from an HMO in which we have an equity
5. We incurred impairment and restructuring charges of approximately $1 million, and
6. We increased our provision for litigation related to California wage and hour and other
matters by $47 million.
The first four items I just mentioned are included in our adjusted EBITDA results, the last two
related to impairment and restructuring and litigation are not. It is, of course, a judgment call as
to which of these items might be non-recurring, not just for the quarter, but for the year. Of
those affecting adjusted EBITDA, the only item which I would rule out from repeating on an
annual basis is the $4 million retroactive portion of the Georgia Medicaid funding. I will talk
more about Medicaid funding in a minute.
Turning to volumes, the 1.0 percent admissions growth we achieved in the first quarter was
within the range used as the basis for our 2008 outlook.
A very strong January, and adequate to good admissions performance in February, was followed
by lower volume numbers in the month of March. Among other factors, there was no
meaningful contribution from flu admissions in March. In fact, flu added only 20 basis points to
our admissions growth for the entire quarter – and was essentially confined to the month of
Assessing the underlying organic growth in admissions in the first quarter is complicated by both
Leap Year and an early Easter holiday. Although we looked at it, and I know others have tried to
measure the impact, we don’t think there is a single correct measure of the effects. Our only real
conclusion is that we were close to our outlook range for the year on admissions, but fell short in
outpatient visits and had a negative payer mix shift away from commercial managed care.
We are still early in the year, and we continue to believe we can achieve our outlook on
admissions of 1 to 2 percent growth, but believe at this point that outpatient visits will more
likely be in the range of 1 to 2 percent as well, rather than our original outlook of 2 to 3 percent.
We believe, however, that the softness in visits and commercial volumes have been and will be
more than offset by favorable pricing.
Now on to revenues, first quarter consolidated net operating revenues rose to $2.4 billion, an
increase of 6.9 percent. Although helped by admissions growth, this 6.9 percent revenue
increase was principally due to strong pricing.
Slide 24 on the web shows that we experienced solid progress in all our key pricing metrics.
Same-hospital revenue per adjusted admission increased by 5.5 percent. The net effect of year-
over-year cost report adjustments and the unusual effects of the retroactive Georgia Medicaid
funding and first quarter HMO distribution, basically offset each other.
In addition to the positive effects of our managed care negotiations and other price enhancement
efforts, we averaged better than expected Medicare pricing in the first quarter.
Before leaving pricing, I want to insert a word of caution that we may experience some
moderation in pricing gains as we proceed through the year. There are four factors:
1. First quarter pricing was influenced by an increase in procedures requiring medical
devices. These higher priced procedures may not continue through the year at the same
2. In the second and third quarter we anniversary earlier pricing enhancements from our
efforts to improve the accuracy of acuity capture in our emergency departments. We will
continue to make refinements as necessary to increase accuracy, although it is still early
to predict to what degree that might result in additional charges being captured.
3. We believe that as we proceed through the year we may experience payor shifts from
higher priced smaller plans to our larger more competitively priced large payers and have
additional shifts between payer categories.
4. Offsetting this there will be additional increases in managed care which are already
We also continue to monitor the status of Medicaid funding in California and Florida. Although
these states continue to face budgetary pressures and we cannot predict the outcome, at this time
we do not believe the effects will be material to our 2008 or 2009 outlook. Based on our current
understanding, the effect on 2008 appears to be less than $10 million.
As you can see there are still a number of variables that will affect pricing for the remainder of
the year. For this reason we have left our pricing outlook range fairly conservative. Obviously,
we will continue to monitor this.
We do believe we have good visibility into our managed care contract pricing for the next two
years, because approximately 84 percent of our commercial rates for 2008 and 68 percent for
2009 are already covered in signed contracts. As the majority of these contracts include
escalators, favorable commercial pricing momentum can be expected to continue.
Turning to costs, the cost strategies we implemented in the second half of last year had a
dramatic and very visible impact on our cost metrics in the first quarter.
Same hospital total controllable operating expense per adjusted patient day increased by just 2.6
percent. This is a very good result and consistent with the walk-forward for 2008 earnings we
shared with you on our fourth quarter call in late February.
Leading this tight cost control picture was an extraordinarily low 2.0 percent increase in same
hospital salary, wages and benefits (SW&B) per adjusted patient day. This growth was below
what we granted in our average merit increases. The low growth in SW&B is, therefore, the
result of declining headcount further supported by the effective management of temporary labor
costs. Some of these savings came from improved employee retention.
Supply costs also were well-controlled with same-hospital growth of 3.9 percent per adjusted
patient day. The growth in prosthesis and implant procedures and costs continued to pressure
this line item, increasing by more than $10 million, or approximately 11 percent.
We also realized a further decline in malpractice expense which declined by $4 million, or
almost 9 percent. This reduction was net of the adverse $5 million impact resulting from lower
interest rates which increased the discounted future liability estimates. Absent the impact of
interest rates we would have achieved a 19 percent reduction in malpractice expense.
Our costs were somewhat negatively affected by increase in length of stay in addition to higher
utilization of medical devices. There was some revenue offset for these, but it does affect cost
performance particularly if you look at it from a per admit standpoint.
On bad debt, as previously mentioned, growth in same-hospital uninsured admissions moderated
in the quarter showing an increase of just 5.4 percent, and uninsured visits declined by 3.8
percent. This growth was well below the 10 percent increase in uninsured admissions
experienced in the fourth quarter. Revenues from the uninsured rose by $18 million, or 12.2
percent on a same hospital basis. This increase in uninsured revenue has been driven by
increases in our chargemaster as well as efforts to improve the accuracy of acuity capture in our
These changes in uninsured charges create a parallel effect on bad debt expense. For the last
three quarters, our refined ED charge capture initiative has been the source of the majority of our
increase in bad debt expense.
Another significant factor influencing bad debt in the quarter was the net growth in the amount
of revenue billed as Balance After Insurance. The increase in “balance-after” added $4 million
to bad debt expense for the quarter.
An offset to bad debt was realized as a result of the resolution of some older disputes with a
commercial payer – the $8 million I mentioned earlier.
So to summarize, bad debt expense grew over the prior year first quarter by $16 million. Pricing
of the uninsured contributed $17 million, an increase in balance after insurance contributed $4
million and several miscellaneous items contributed an additional $3 million, for a total of $24
million. Bad debt was reduced by the aforementioned resolution of some older disputes with a
commercial payer by $8 million. Since this settlement related to relatively old accounts
receivable, this cash had virtually no impact on our receivables.
Switching the focus to accounts receivable, slide 27 on our Web site, shows that the AR increase
was concentrated in the zero-to-90-day bucket, with both the 91-180 day and the over 180 day
buckets showing improvements. Managed care and aggregate self-pay collection rates remained
stable in the first quarter based on our 18 month look-back analysis.
While same-hospital uninsured admissions and revenues were up over prior year first quarter,
charity was down, making this another quarter in which there are opposing trends. As we have
stated on prior calls, it is difficult to trace the precise cause and effect on this. But we continue
to believe that our strategies to emphasize favorable product lines, educating patients on the
appropriate source for healthcare services and assisting patients with available funding options
are mitigations to what is a key risk in the industry.
Turning to cash flow and capital expenditures, as we discussed on our fourth quarter call, capex
in the first quarter included some “spill-over” from the fourth quarter. Accordingly most of the
capital spend in the quarter occurred in January as we paid for equipment which was delivered or
in the pipeline at the end of last year.
We still intend to adhere to our earlier outlook of $600-$650 million in capex in 2008. As we
also stated in our fourth quarter call, we anticipated that our capital spending would be more
balanced over the first and second half of the year, with significantly less concentration in the
fourth quarter. I should also note that we have received regulatory relief with respect to certain
of our California hospitals, which will reduce our seismic requirements over the next several
years. Although not likely to be significant this year, we are still determining how large the
aggregate effect will be.
With respect to cash flow, the earnings release lays out a fair amount of detail on the cash flow
of the quarter and how it compares to last year.
You may recall that adjusted cash flow from continuing operations came in lower than
anticipated in the fourth quarter of last year, primarily due to working capital. I indicated in the
year-end earnings call that we were focused on payables and overdraft management and in
reducing days in accounts receivable over the course of 2008. In the first quarter we improved
our payables position consistent with our objectives. The improvement in accounts receivables
is still ahead of us, but we held the line in the first quarter with days in receivables flat against
last year end at 54 days. We are still targeting a two-day reduction in receivables days by the
end of the year.
Accordingly, receivables grew in the quarter proportionate to the growth in revenues, and as I
just said our growth in AR was in the “zero to 90 day” bucket.
Given $66 million in debt service and a $24 million payment to the DOJ in the second quarter, in
addition to continuing capital investments, our June 30 cash position is likely to be modestly
below the March 31 cash balance. June 30 is expected to mark our quarterly low-point in cash
for the year.
Going forward we expect cash to build as a result of stronger operating cash performance in the
second half of the year, our initiatives to produce $400 to $600 million of cash from balance
sheet improvement actions, and the resolution of the USC matter. The respective upside and
downside from there would largely be favorable resolution of the Redding insurance arbitration,
and the contingency reflected in our increased litigation reserve.
In terms of the $400 to $600 million in initiatives, progress is being made. The MOB transaction
is moving along as we have selected Jones Lang LaSalle as our broker on the transaction, and we
expect the formal offering announcement and related documents to go out in the next couple of
weeks. There is a slide on the Web giving some high-level information on the MOBs we own
and are being offered. We also continue to work with the other shareholders and the board of
Broadlane to establish an approach to monetization of current shareholder interests.
Accordingly, we still expect the list of action items making up the $400 to $600 million to be
completed by roughly the end of next year, although much of it could be and should be sooner.
Some of you have asked about earnings loss from these balance sheet initiatives. From a bottom
line income standpoint, we expect the interest income generated from the cash proceeds to be
sufficient to offset any loss of EBITDA generated presently by these assets. Looking at
EBITDA alone, I don’t believe we will have a loss of EBITDA sufficient to change our
expressed outlook range for 2008 and the one billion or better in EBITDA targeted for 2009.
Moving to the outlook, slide 29 gives our current outlook for the key metrics of financial
performance. The 2008 outlook continues to include 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. At this time we are holding that outlook as we are the outlook on cash flow
and year-end cash. I will remind you though that the cash outlook does not include any of the
anticipated $400 to $600 million cash proceeds I just discussed. Nor does our outlook reflect
any effects of a sale of USC, the Redding arbitration, or the litigation for which we have
We are adjusting our outlook for outpatient visits slightly as I described earlier, and offsetting
that with improved pricing. We have updated the 2008 and 2009 walk-forward chart on the Web
to show these effects.
In the prior quarters I have done rather detailed, if not tortuous, walk forwards from year-to-date
actuals to our outlook. This quarter I am happy to say that outside of the offsetting changes to
visits and price I just referred to, there is no real need to establish a new reconciliation of actuals
to the outlook.
Let me now ask our operator to assemble the queue for questions.