Participants

William McDowell; Vice President - Investor Relations; Tenet Healthcare Corp

Saumya Sutaria; Chairman of the Board, Chief Executive Officer; Tenet Healthcare Corp

Sun Park; Chief Financial Officer, Executive Vice President; Tenet Healthcare Corp

Pito Chickering; Analyst; Deutsche Bank

Jamie Perse; Analyst; Goldman Sachs & Company, Inc.

Brian Tanquilut; Analyst; Jefferies & Company, Inc.

Andrew Mok; Analyst; Barclays

Justin Lake; Analyst; Wolfe Research

Benjamin Rossi; Analyst; J.P. Morgan Securities LLC

Joanna Gajuk; Analyst; BofA Global Research

AJ Rice; Analyst; UBS

Stephen Baxter; Analyst; Wells Fargo Securities, LLC

Michael Ha; Analyst; Robert W. Baird & Co. Incorporated

Ann Hynes; Analyst; Mizuho Securities USA

Whit Mayo; Analyst; Leerink Partners

John Ransom; Analyst; Raymond James & Associates, Inc.

Josh Raskin; Analyst; Nephron Research

Matthew Gillmor; Analyst; KeyBanc Capital Markets Inc.

Mike Murray; Analyst; RBC Capital Markets

Presentation

Operator

Good morning. Welcome to Tenet Healthcare's fourth-quarter 2024 earnings conference call. (Operator Instructions)
I'll now turn the call over to your host, Mr. Will McDowell, Vice President of Investor Relations. Mr. McDowell, you may begin.

William McDowell

Good morning, everyone, and thank you for joining today's call. I am Will McDowell, Vice President of Investor Relations. We're pleased to have you join us for a discussion of Tenet's fourth-quarter 2024 results as well as a discussion of our financial outlook. Tenet senior management participating in today's call will be Dr. Saum Sutaria, Chairman and Chief Executive Officer; and Sun Park, Executive Vice President and Chief Financial Officer.
Our webcast this morning includes a slide presentation, which has been posted to the Investor Relations section of our website, tenethealth.com. Listeners to this call are advised that certain statements made during our discussion today are forward-looking and represent management's expectations based on currently available information.
Actual results and plans could differ materially. Tenet is under no obligation to update any forward-looking statements based on subsequent information. Investors should take note of the cautionary statement slide included in today's presentation, as well as the risk factors discussed in our most recent Form 10-K and other filings with the Securities and Exchange Commission.
And with that, I'll turn the call over to Saum.

Saumya Sutaria

Thank you, Will, and good morning, everyone. We delivered outstanding performance in 2024, characterized by strong same-store revenue growth, disciplined operations, and effective capital deployment. In addition, the year was highlighted by portfolio transactions that have transformed our franchise to be well positioned for long-term growth with strategic flexibility and a deleveraged balance sheet.
We reported 2024 net operating revenues of $20.7 billion and consolidated adjusted EBITDA of $4 billion, which represents 13% growth over 2023. Full-year adjusted EBITDA margin of 19.3% improved over 200 basis points from prior year.
Our fourth-quarter results were above our expectations, driven by continued same-store revenue strength, high acuity growth, as well as effective cost management. Our disciplined approach has enabled us to consistently exceed our performance expectations each quarter this year, furthering our track record. I would note that our full-year adjusted EBITDA ended the year over $600 million higher than the midpoint of our initial expectations, driven by strong growth and operational performance.
USPI had a fantastic year in 2024. We generated $1.81 billion in adjusted EBITDA, which represents 17% growth over 2023 and adjusted EBITDA margins of 4%. Same-facility revenues grew 7.8% in 2024, another year substantially above our long-term goals.
High acuity volume growth was highlighted by total joint replacements in the ASCs, up 19% over prior year. Importantly, customer service levels in our centers remain quite high as we earned a 96.6 overall patient experience score in 2024.
Turning to our hospital segment. Despite the sale of 14 hospitals during the year, we generated $2.185 billion of adjusted EBITDA in 2024, which represents 9% growth over prior year. Same-store hospital admissions were up 4.7%, as we continue to open up capacity to respond to a strong utilization environment. Acuity and payer mix were strong throughout 2024 and drove a 4.6% increase in same-store revenue per adjusted admission over prior year.
This was an important year for Tenet, as we transformed our portfolio of businesses through the multiple high-multiple sales of 14 hospitals and related operations, generating $5 billion in gross proceeds and enabling significant balance sheet deleveraging. In addition, we added nearly 70 ambulatory surgical centers to the portfolio in 2024 as we were very active in both M&A and de novo development.
And finally, over the past two years, we have returned capital to shareholders via share repurchase, retiring approximately 14% of our outstanding shares for $1.12 billion since our repurchase program began in the fourth quarter of 2022.
Going forward, we plan to be active repurchasers of our shares, particularly at our current valuation multiples. These actions have resulted in a portfolio of businesses that is more predictable, capital efficient, and able to operate in a variety of environments with better margins and ample free cash flow for the benefit of shareholders. In summary, we're very pleased with our team's performance in 2024, and we believe that we will carry this momentum into the new year.
Turning to 2025 guidance. We are projecting full-year 2025 adjusted EBITDA of $3.975 billion to $4.175 billion, which is an attractive 7% growth rate at the midpoint on a normalized basis. We anticipate adjusted EBITDA growth at USPI of approximately 8.5% at the midpoint of our guidance for '25 based on our expectation of 3% to 6% growth in same-facility revenue, fueled by ongoing strength in demand and acuity, continuing effective operational execution, and additional sites of care joining the portfolio.
We intend to invest approximately $250 million each year towards M&A in the ambulatory space. And the pipeline of opportunities remain strong. We anticipate adding 10 to 12 de novo centers in 2025. Our ability to consistently scale our platform to create additional low-cost sites of care for patients and physicians continues to pay dividends, as it improves our overall growth, profitability, capital efficiency, and resiliency in this regulatory environment.
Turning to our hospital segment. We are expecting adjusted EBITDA growth of approximately 5.7% on a normalized basis at the midpoint for 2025. This projected is going to be driven by 2% to 3% adjusted admissions growth and the strong operating discipline that our team has now demonstrated for many years.
The hospital segment's performance will be enhanced by strategic capital deployment, expanded service lines, and further contributions from the new Westover Hills facility, which opened in the third quarter of 2024. Additionally, as we have noted, we have expanded the relationships that Conifer has with acquirers of hospitals we've sold, and this should contribute to growth in 2025.
Finally, we acknowledge that there is currently a great deal of focus on the impact of potential regulatory changes in our space. We have demonstrated an ability to perform well in a variety of operating environments, and believe we are differentiated from our peer set as we navigate potential changes going forward. For example, our ASCs operate with freestanding ASC rates, which insulates that important part of our business from potential changes in site neutrality rules.
In summary, we had an outstanding year in 2024 and believe that we are in a great position for another strong year in 2025. Our guidance reflects the opportunities before us and the momentum that we carry into the new year. Our established management team stands ready to execute our focused strategy and deliver value for patients, physician partners, and in turn, shareholders.
And with that, Sun will now provide a more detailed review of our financial results. Sun?

Sun Park

Thank you, Saum, and good morning, everyone. We are very pleased with the strong finish to the year. In the fourth quarter, we generated total net operating revenues of $5.1 billion and consolidated adjusted EBITDA of $1.048 billion, which represents an adjusted EBITDA margin of 20.7%, up almost 200 basis points from fourth quarter of '23.
For full-year '24, we generated $20.7 billion of total net operating revenues and consolidated adjusted EBITDA of $3.995 billion. These results were driven by strong same-store revenue growth, continued high patient acuity, favorable payer mix, and effective cost controls.
Now I'd like to highlight some key items for each of our segments, beginning with USPI, which again delivered strong operating results. In the quarter, USPI's adjusted EBITDA grew 14% over last year with adjusted EBITDA margin at 42.1%. USPI delivered an 8.6% increase in same-facility system-wide revenues, driven by high acuity levels and favorable payer mix. Same-facility system-wide surgical case volume grew slightly over last year.
And turning to our hospital segment. Fourth-quarter adjusted EBITDA was $518 million, with margins up 90 basis points over last year at 13.6%. Normalized for the divested hospitals, adjusted EBITDA grew 13% over fourth quarter of '23. Same-hospital inpatient admissions increased 5%, and revenue per adjusted admission grew 0.6%.
Our consolidated salary, wages, and benefits in fourth quarter of '24 was 41.3% of net revenues. And our consolidated contract labor expense was 2.1% of SWB, both substantially lower than the 43% and the 2.8%, respectively, that we reported in the fourth quarter of '23.
Next, we will discuss our cash flow, balance sheet, and capital structure. Our cash flow performance was very strong in '24 with $1.1 billion of free cash flow for the year. This includes the payment of $855 million in income taxes related to our completed divestitures.
Excluding these tax payments, this represents nearly $2 billion of free cash flow for the year or $1.3 billion of free cash flow after distributions to noncontrolling interests or NCI. For full-year 2024, we repurchased 5.6 million shares of our stock for $672 million. We finished the year with over $3 billion of cash on hand, with no borrowings outstanding under our $1.5 billion line of credit facility.
Our year-end leverage ratio was 2.5 times EBITDA or 3.2 times EBITDA less NCI, a substantial improvement over the past year, reflecting the proceeds that we received from our hospital divestitures as well as our outstanding operational performance. We are very pleased with our ongoing cash flow generation and have a commitment to a deleveraged balance sheet. We believe we have significant financial flexibility to support our capital allocation priorities and drive shareholder value.
Let me now turn to our outlook for 2025. We expect consolidated net operating revenues in the range of $20.6 billion to $21.0 billion. Our projected consolidated adjusted EBITDA is in the range of $3.975 billion to $4.175 billion. As a reminder, there are two normalizing items that I would call out when comparing our '25 adjusted EBITDA to the prior year.
First, we reported $114 million of adjusted EBITDA from facilities that we divested in '24 and will not recur. Additionally, we reported $74 million of out-of-period supplemental Medicaid payments in Michigan and Texas in '24. After normalizing for these items, our '25 adjusted EBITDA is expected to grow 7% at the midpoint of our range.
Our '25 outlook assumes continued growth in same-store volumes and effective pricing, as well as strong operational efficiencies and disciplined cost controls. Additionally, we anticipate further contributions from recent investments and partnerships in the hospital segment, as well as from M&A and de novo center openings at USPI. In addition, we are also assuming the following: same-hospital admissions growth of 2% to 3% and adjusted admissions growth of 2% to 3%; and for USPI, same-facility revenue growth of 3% to 6%.
On a normalized basis, we expect adjusted EBITDA to grow 8.5% at USPI and 5.7% for our hospital segment at the respective midpoints of our guidance ranges. Our outlook also assumes $35 million of net revenues from the Tennessee supplemental Medicaid programs. About one-third of this increase is related to the second half of '24 and is expected to be recorded in the first quarter of this year.
Finally, we would expect first-quarter 2025 consolidated adjusted EBITDA to be in the range of 24% to 25% of our full-year consolidated EBITDA at the midpoint. We anticipate that USPI's EBITDA in the first quarter of this year will be 21% to 22% of our full-year USPI EBITDA at the midpoint.
Turning to our cash flows for '25. We expect cash flow from operations in the range of $2.5 billion to $2.85 billion, capital expenditures in the range of $700 million to $800 million, resulting in free cash flows in the range of $1.8 billion to $2.05 billion. In addition, we're also assuming distributions to NCI in the range of $750 million to $800 million, which would result in free cash flow after NCI in the range of $1.05 billion to $1.25 billion.
And finally, as a reminder, our capital deployment priorities have not changed. First, we will continue to prioritize capital investments to grow USPI through M&A. Second, we expect to continue to invest in key hospital growth opportunities, including our focus on higher acuity service offerings. Third, we will evaluate opportunities to retire and/or refinance debt.
And finally, we'll have a balanced approach to share repurchases, depending on market conditions and other investment opportunities. Given our attractive free cash flow profile and current valuations, we plan to be active repurchasers of shares in 2025.
In conclusion, we had an outstanding year in 2024, with effective operational execution, robust growth, and a transformed portfolio of businesses. We're confident in our ability to deliver on our outlook for '25 and continue to drive value for patients, physician partners, and shareholders.
And with that, we're ready to begin our Q&A. Operator?

Question and Answer Session

Operator

(Operator Instructions) Pito Chickering, Deutsche Bank.

Pito Chickering

Good morning, guys. Thanks for taking my question. So looking at Tenet sort of in the last few years, the biggest change has been the cash flows and your deleveraging. Your cash flow guidance for this year is up 90% year over year or nearly $1 billion more cash flow from operations.
So looking at your cash flow guidance for this year after NCI, it's about $1.15 billion at the midpoint. If we pull out $250 million for M&A, it's about $900 million left to deploy with a leverage at sort of 3.2 times EBITDA less NCI. Can you refresh us on what your ideal target leverage ratios are? And should we be modeling the rest of that going to share repo at this point? Thank you.

Saumya Sutaria

Hey, Pito. It's Saum. First of all, I appreciate reiterating the improvements that we've made in generating free cash flow from this business from operations. It's obviously been a very important part of our goal over the last few years and getting to this point probably earlier than we thought.
We're very comfortable with the leverage that we operate at today. And importantly, it gives us -- we look at it and say it gives us significant strategic flexibility with respect to the business, both in terms of activity that we may pursue in growing and scaling USPI, as I noted in my comments, but also from the perspective, especially, as I said, at these valuation multiples in terms of share repurchase.
And both Sun and I noted that we would plan to be active repurchasers of our shares at these multiples, makes complete sense. We don't have debt coming due for a couple of years, right? I mean, so we're not in any situation of urgency there regardless. And I think the return on share repurchase at this point would be higher anyway.
So our thinking is relatively clear about that in the coming years. Obviously, we need to continue executing operationally with the track record that we've built to generate that free cash flow. But as we've talked about in the last couple of years, we've really hardwired our approach there.
The last thing I would point out, in addition to what I said about USPI in my comments, we don't -- USPI does not have a tremendous amount of Medicaid exposure. So when you think about utilization of our cash flows and regulatory risk that may be out there, I mean, the reality is half our EBITDA is generated in the segment that isn't really facing risk from any scenario out there related to Medicaid programs.
And that's very helpful. It's very different than it might have looked five or six years ago. So we feel confident about the valuation opportunities for the company.

Operator

Jamie Perse, Goldman Sachs.

Jamie Perse

Hey, good morning. Thanks for taking the question. Can you maybe spend a minute on just the volume environment that you're seeing today?
Obviously, 2023 and 2024 were pretty strong years. Some of that just recovery and normalization post the pandemic. Where do you think we're at from a volume perspective today? And how do you expect volumes to progress throughout the course of the year?

Saumya Sutaria

Yeah, thanks, Jamie. I mean, the simple statement I would make right now is that we've anticipated the volume environment continuing to be strong coming into 2025. I mean, that's the simplest summary statement I would make.
We don't -- there aren't obvious trends from December 31 to January 1 that appear to have changed. I mean, the coverage environment looks good. The employment environment looks good. Demographics, both in terms of areas where, at least, our portfolio is now positioned relative to where it was, has attractive demographics.
And as we've noted, we've had opportunity to expand capacity and take on that capacity without excessive cost to do so. And we're doing it in a deliberate way. So we -- I mean, our guidance reflects that. We feel pretty good about going into 2025.

Jamie Perse

Okay. Thank you.

Operator

Brian Tanquilut, Jefferies.

Brian Tanquilut

Hey, good morning, guys, and congrats on the quarter. Maybe, Saum, as I think about your comments on Medicaid and USPI, just curious how you're thinking about the risk overall for the company from all the political headlines that are out there and what the Republicans are trying to do with changes to healthcare policy, and what you're doing to prepare for that just for that potential change, whether it's Medicaid or health insurance exchanges across both business lines. Thanks.

Saumya Sutaria

Yeah, thanks, Brian. A few things. So I mean, first of all, the fundamental underpinnings of success in an environment with any kind of uncertainty, in our view, is operating discipline in what we do, right? And the other important underpinning is having a clear understanding of the economics of our business internally; meaning, we understand clearly our service lines, our markets, et cetera, that may have greater dependency or less dependency upon certain types of supplemental payments where, for example, the strength in the exchanges has contributed to earnings, et cetera.
So the combination of the operating discipline and the insights about the business probably give us an opportunity to manage and pivot as needed depending on what happens. You're right; the segments are different.
I mean, we've taken the opportunity over the past few years to create resiliency in USPI by making sure that the ambulatory surgery centers as a part of USPI are on freestanding rates. The Medicaid exposure is de minimis in that business, and that's very helpful from that perspective. And the exchange business there has had less impact than it had on the acute care segment in terms of the exchange growth from that perspective.
So from a USPI perspective, look, this is all about an important tailwind of moving things into a lower-cost setting in an expensive portion of the healthcare industry, which is surgical care, right, and doing so in a way where we're constantly increasing the acuity of the work at USPI because it creates more value for the purchaser.
On the acute care hospital side, I think it's important to continue to search for efficiencies that allow us to generate margins. We always talk about the concept of Medicare profitability, right? Can you generate margins on Medicare reimbursement in order to have a metric out there for efficiency goals that you would create? Because it's important to be able to operate in that type of environment.
Specifically on the acute care side, the number one adaptive action today is helping the regulators understand the importance that these programs provide for basic access for people that wouldn't otherwise have access to care. And that's really important because if that shapes -- or is a factor in shaping policy, I think that what comes out of that policy will likely be manageable for us and something that we can get behind.
I'm not sure that right now taking a bunch of actions to restructure the business is the right thing to do. I think there's a very strong case to be made that many of these things are really critical to providing access. And it happens to be that that access is also being provided in states with voters that really matter to this administration. And that's an important supporting factor as well.

Operator

Andrew Mok, Barclays.

Andrew Mok

Hi, good morning. When I look at the ASC case mix from '23 to '24, it doesn't look like there are significant mix changes. We actually see MSK down 1 percentage point; in ophthalmology, up 1 percentage point.
But you're increasing acuity significantly to the point where you're seeing high single-digit same-store revenue growth without meaningful case growth. So can you speak to the types of cases driving acuity higher? Because it's not obvious from the case mix disclosures. Thanks.

Saumya Sutaria

Yeah, no problem. I mean, just to clarify, the orthopedics line item has a lot of things in there. That's why we call out the highest acuity work in joint cases, for example, which is where you have the hips, knees, obviously, the shoulder expansion. That's where the acuity is actually growing.
I mean, remember, when you look at certain low acuity procedures that we may do in ASCs, the revenue per case is an eighth or ninth of a single joint case, total joint case from that perspective. So I mean, we're doing exactly what we wanted with the business, which is we're growing the acuity.
We're growing the net revenue per case. We are reducing exposure to high-volume, low-revenue cases; in some cases, things that could also be done in offices that further strengthen the resiliency and value of what USPI is building.
So that orthopedics line item has a lot of things in there from high acuity to low-acuity cases. And it's the reason we call out the really high acuity work. That's a fundamental driver of the net revenue per case strength, which you're seeing.

Andrew Mok

Great. Thanks for the call.

Saumya Sutaria

Sure.

Operator

Justin Lake, Wolfe Research.

Justin Lake

Thanks. Good morning. A couple of things just numbers-wise. Maybe you could tell us -- you've mentioned Tennessee as a tailwind, that $35 million. You mentioned, for instance, Michigan is not going to -- you're going to have a little bit of a one-time headwind there.
But when you think about ex those issues kind of core DPP dollars year over year, can you tell us what's assumed in the guidance? And then the same for exchanges, like what kind of exchange growth do you kind of expect in your markets, exchange volume growth within that guidance? Thanks.

Sun Park

Hey, Justin. It's Sun, and thanks for the question. On your question about supplemental payments, yeah, I think you called out the kind of the one-timers that we've referenced. The other point, in fiscal '24, is we still had a little bit of value from hospitals that were divested during the course of the year. But that's mostly in Q1. So there are a couple of those moving factors.
But in fiscal '24, we generated about $1.16 billion of Medicaid supplemental payments. Going into '25, our guidance assumes something pretty consistent with that. You mentioned the Tennessee one-time. But excluding that, we're pretty consistent year over year.
On your question about exchange, as we've said multiple times, total admissions and revenues from exchange population was a strong growth driver in 2024. We expect that to continue, per Saum's earlier comments around the overall volume environment.
The enrollment -- the renewal cycle seems to have been positive. We'll see how much of that turns into actual admissions. But we certainly won't see the 40%, 50% growth that we saw in '24, but we still continue to see a strong environment.
Just as an example, we're -- our strategy -- long-term strategy has always to be in broad networks from a contracting standpoint as an example. So we see good things for '25. Thanks for the question.

Operator

Benjamin Rossi, JPMorgan Chase.

Benjamin Rossi

Hey, good morning. Thanks for the question here. So just across supplies where -- seem some pressure here as a percentage of revenue with that category increase in about 100 bps year over year to 18.3. How would you characterize your current supply dynamics exiting the quarter?
Is there anything discrete occurring within there? Is this largely a byproduct of your push in the higher acuity? Just kind of curious where you're seeing that number settling out in the steady state during 2025. Thanks.

Saumya Sutaria

Yeah. Hey, Ben. Yeah, I think it's what you said on the latter piece. It is a just kind of part and parcel with our acuity strategy. So the supplies will go up as a percentage a little bit in Q4. But over the year, we've been pretty well balanced. And we expect it to be, again, balanced in '25.

Benjamin Rossi

Got it. Thanks.

Saumya Sutaria

Thank you.

Operator

Joanna Gajuk, Bank of America.

Joanna Gajuk

Hi, good morning. Thanks so much for taking the questions. So on the guidance element -- and both are same-store revenue 3% to 6%, right? That seems to be sort of more like a normalized growth because, clearly, you grew very nicely in '24, almost 8%. So is it just conservatism? Could you maybe also break down volumes versus pricing that's included in that range? Thank you.

Saumya Sutaria

Yeah, hey, it's Saum. Look, a couple of things there. First of all, long term, as we've learned with USPI -- and I think we've shared this data before. We've looked at 10 years' worth of USPI's performance, and same-store growth rates of around 4% to 6% is what we guide to.
Now history suggests over that 10-year period, we've performed at the upper end of that range, 6%. That has looked better strengthened over the last five, six years, actually over that average period, okay? So you point out -- this year, almost -- or this year, past year, '24, 7.8%. The prior year was 9.2% growth rate.
So we're running very hot from that perspective in terms of long-term averages with respect to USPI. So our guide just comes -- brings us right back to what our long-term growth rate is. In terms of the year to year, as you've seen, it can be lumpy, right? '23, huge volume growth; '24 more growth in acuity and intensity.
And part of what we're signaling for '25 is it's definitely our plan to continue the shift to higher acuity procedures. I started to point out some of the factors driving that in terms of the revenue intensity of some of these cases, how efficiently we're able to do them in our operating rooms now and generate margin, how we are scaling those programs into more centers.
We now have robots in almost 150 of our programs around the country. This is the direction in which we're taking the organization. So yeah, the guidance reflects kind of our long-term average. But we've obviously been running quite a bit above that.

Operator

AJ Rice, UBS.

AJ Rice

Hi, everybody. Saum, I would ask you maybe on where you're at with managed care contracting. I know we've been in a period where you've been getting a little bit toward the high end of historical rate updates to pay for some of the labor challenges in the last few years.
Is '25 a year in which you'll still type of dynamic, maybe where are you at in terms of signing up contracts? And then also on the managed care side, any update on thoughts about denial activity, prior authorization challenges, and other term changes that you're dealing with?

Saumya Sutaria

Yeah, why don't we take those in reverse. The -- I mean, I would say that the environment is no different than it has been. I mean, there's a constant back and forth of administrative costs that goes into adjudicating claims that probably is unnecessary. But obviously, both sides have a point of view on that.
What I would say, more importantly than anything else from our perspective, is the work that Conifer does in driving initial disputes to a very, very attractive low rate of denials is critical. And our skill set in doing that in both working collaboratively with the payers and adversely where needed on the basis of solid documentation, appropriate coding, compliant coding, and efficient revenue cycle operations, has made a big difference.
We're seeing a gap in what we generate in terms of lower denial rates than the industry from what we are seeing with respect to initial dispute rates. And that's good because that means we're doing things right in generating the appropriate cash flow from the work we're doing.
Sun, maybe you want to comment on the managed care side.

Sun Park

Yeah. Thanks, Saum. AJ, for your first part of the question, as we've said historically, we are continuing to see commercial rates increases in the 3% to 5% range. And some of the contracts have been at or slightly above the high end of that range, with respect to the inflationary pressures that you've mentioned.
So I think the overall situation there is pretty consistent. And then in terms of contracting, going to '25, we're over 90% contracted for '25 and probably about over 50% contracted for '26 as well. So we have great visibility into '25 and beyond. Thanks for your question.

Operator

Stephen Baxter, Wells Fargo.

Stephen Baxter

Hi, thanks. I wanted to come back to the same-store hospital volume guidance for 2025. I appreciate you're still expecting exchange growth inside of that number to some degree.
I would also love to hear any quantification you can offer about how much hospital capacity you'll have online in 2025 compared to 2024? Trying to break out that 2% to 3% and maybe think about maybe what's the market level growth inside of that compared to how much of it is coming from capacity. Thank you.

Saumya Sutaria

Yeah, hey, Stephen. It's obviously both. I mean, the majority of that is the market level demand that we're seeing versus the selective markets in which there's still capacity that we're bringing online. But it is a contributor which is why I called it out before. We haven't quantified what that looks like between the two numbers. But it is both, and the majority of it is market-based demand across the board.
Some of this is also related to the service line choices we make, of course, which have higher growth rate. The things that we're doing that are taking care of people with multiple chronic illnesses that continue to grow in prevalence are continuing to create more demand than, perhaps, certain types of lower acuity work, which may be coming out of hospitals in our environment. And so that's really how we think about it in terms of the growth rates.
Yeah, look, it's been a very busy year in the acute care environment. And as I said, I think the most important thing we're taking into the year from a mindset perspective is, we're not seeing changes in the demand patterns. It was a comment to Jamie's question earlier. We're not seeing changes in the demand pattern right now. And so I mean, I'm not going to go forecasting what we may see in the later part of the year, but we're not seeing that right now.

Operator

Michael Ha, Baird.

Michael Ha

Hi, thank you. Just a quick clarification first, and then my real one. And apologies if I missed it, but your USPI at 3% to 6% growth guide, what's the volume versus pricing split on that? And then my real question -- I'm sorry to add one more question on policy.
And I understand USPI has minimal Medicaid exposure. But for your hospital and maybe taking a different approach, just given all the news flow, NIH cuts, DOGE's potential focus on Medicaid administrative cuts. If DOGE were to implement those cuts, it might not be overly impactful, but still, perhaps, a couple of percent of overall Medicaid spend.
So I'm curious to hear your view, if that were to happen, how do you think states might react? What's your view on the likelihood that states might potentially slow that Medicaid cut down to provider rates and impact kind in hospitals more broadly? Thank you.

Saumya Sutaria

Yeah. A couple of different things. So let's just start with the business side of it first. With respect to USPI, as I indicated, there's no long-term deviation from our approach of thinking about half and half roughly managed care and volume at USPI. But because it's lumpy and it's proven to be lumpy, we're not guiding specifically for the year with respect to that.
And you can understand that. I mean, we're successfully now two years in a row executing our strategy of increasing lower-volume, high-acuity cases. And in fact, as you can tell from our quarterly beats, consistently, we're exceeding what we expect from the standpoint of what we can do in same-store revenue growth in that environment.
And so we're pleased by that, that we can do that. We obviously had a little bit of fits and starts around that a few years ago in terms of how we were executing it. But we got it right, and it's working. And I'm really pleased with that.
So the long-term algorithm is the same. But from a short-term standpoint, we're giving you the revenue guidance with, obviously, the track record of it being stronger. I don't -- on the policy side, I think to be clear, we don't have -- even in our academic medical center enterprises and affiliations, we don't have significant NIH or NSF indirect grant cost exposure in our business.
So in particular, as you can imagine, when we saw that, we thought about that in our environment and where we had [RON] grants and other things within our environment. But we don't have that significantly in our environment.
I think the broader question of Medicaid policy and other things is an important one. But, look, the focus on -- that is articulated -- and you can't tell what's going to happen. But the focus that's articulated on reducing fraud and abuse, including in some of the public comments made yesterday all the way in the Oval Office, I think one thing that people may find is that Medicaid redeterminations over the last couple of years have probably done a lot to reduce the number of people eligible or not eligible who happened to be on Medicaid.
And so I'm -- again, no way to predict, for sure. But I I'm somewhat comforted by the fact that some of that work has already been done through this redetermination process. So we'll see where this goes and what remains to be seen.
Finally, as to speculation -- speculating on what the state's responses may be, I think the states are going to be important allies across the board in advocating for the dollars that come through these Medicaid partnerships with the federal government. Because, again, I go back to -- this is the only way to create access for the people that need it that are on Medicaid.
This is not some program that's generating incredible windfalls for health systems on that basis. The unit reimbursement is still below the cost of that care. And so I think that that's going to be an important balancing factor. The states will play an important role in this.

Operator

Ann Hynes, Mizuho.

Ann Hynes

Hi, good morning. So I know there's some big surgery center assets out there in the market. Can you remind us, given your delivered balance sheet, what your appetite is versus larger-scale M&A in the surgery center business?

Saumya Sutaria

Hey, Ann, it's Saum. Obviously, I'm not going to comment on any kind of M&A opportunities. We're very aware of everything that's available in the market. We've proven our ability over the last few years to deploy M&A capital both on a single-asset basis and large multicenter asset acquisitions.
I would tell you that the first year post our acquisition early last year of the portfolio that we took on went better than we thought it would. So that's good news. And as I said early on in my comments, our balance sheet provides us plenty of flexibility to approach things.
But, look, we're disciplined. We believe in growth businesses. We believe in areas in which we can add value. And we have a lot of flexibility given our cash flow generation and valuation multiple to deploy cash for the benefit of shareholders in multiple different avenues at this point.

Operator

Whit Mayo, Leerink Partners.

Whit Mayo

Hey, good morning. Just to stick on USPI for a second. Are there any new health system partners that we may not be aware of in the last year? I know you've been selective and disciplined with the financial strength of the partners that you want to work with.
But I'm just not sure I've had an update or heard an update on anything new or any expanded relationships with any health systems in some time. And maybe just a broader comment on the de novo activity, the 10 to 12 this year. Any of those with new partners, or those are all existing partners? Thanks.

Saumya Sutaria

Yeah. Hey, Whit, it's Saum. No, we haven't provided any updates on health system partners and other things. And remember, I mean, our platform is such that we work just as effectively with partners as we do without partners because of our ability to generate contract synergies, managed care, supply chain, everything, right, in our management capacity for these assets.
So we're growing the portfolio in both -- with both vectors. And I don't think that's going to change. I mean, I think the expansion of de novo assets can occur in many different ways. Some are in existing markets. Some are in new markets.
Some are with MSOs that are expanding their physician side footprint and as I've said in the past, have realized that there isn't a better operator of ASCs to generate margin from those investments for those doctors than USPI. So that's another vector of growth that is helping to create de novo activities. It's a multipronged growth strategy, and I don't think that's really going to change looking forward.

Operator

John Ransom, Raymond James.

John Ransom

Hey, good morning. Saum, I predict you'll hate this question, but bear with me. So we've heard from a few folks that the fourth-quarter seasonal uptick is not quite what it used to be because just the fact that deductibles have gotten so high, particularly in commercial plans. Do you think there's any evidence of that?

Saumya Sutaria

So, John, are you referring just care delivery overall or USPI specifically?

John Ransom

I'm sorry, I meant electives. So electives either in the hospital or in the USPI.

Saumya Sutaria

Yeah, elective work. Yeah. Well, it's -- I mean, again, I'm not sure that I'm going to be able to give you a statistically significant answer. But I would say that the seasonality in Q4 -- and especially that ramped into Q1 on elective surgery -- it has tempered a bit.
I mean, Q4 is still a more productive quarter. Our asset utilization in our USPI segment does go up still in Q4. But it has tempered a bit overall. And also -- and how much of it is the deductibles versus somewhat the impact of -- if you look at our Q4, the impact of just some of these weather events were relevant.
And so how much of it was a seasonality shift versus some of the weather events that we -- I don't know that we've really calculated that. But it is -- I mean, you're picking up on something that we've sort of said, intuitively, it feels a little bit different. But the general pattern hasn't changed.

John Ransom

And so just a follow-up -- and thanks for that answer. If we look at '23 and '24, utilization was up for -- in '23. I'd say, electives in '24, there was a bunch of other stuff going on like two-midnight rule and cancer cases and what have you.
Do you think -- again, probably, you can't answer this question. But it seems to us like '25 were kind of back to more kind of a normalized year, where maybe we've cleared out all the COVID backlog, and we're kind of clear all of these kind of wonky events in '23 and '24. Is that kind of your -- is that what's implied in your guidance? Is that's kind of where we are?

Saumya Sutaria

I mean, that is kind of -- I mean, at some point, we have to get back to an environment where we're not explaining everything, either on the basis of COVID or post-COVID or whatever the case may be. No one ever gets that entirely right. But I do think that that is a little bit of what the guidance implies.
And as I said, I think that's a fair way to plan for the year. And yet at the same time, I don't see shifts necessarily in the strength -- the strong demand environment that we saw in '24 yet, in particular. So we'll see how that plays out.

John Ransom

Thank you.

Saumya Sutaria

Thanks.

Operator

Josh Raskin, Nephron Research.

Josh Raskin

Thanks. I'm going to stick on the USPI topic. So can you speak maybe to the broader competitive landscape for ASC transactions? Are you seeing more competition? And if you could differentiate between larger sets of assets or even one-offs or even competitors developing de novos in your markets?
And then in your prepared remarks, Saum, you mentioned the de novo growth. Is that indicative of more, what we'll call, sort of organic center expansions as opposed to acquired centers?

Saumya Sutaria

Well, let me go in reverse. Look, we think de novo development activity is really critical, and we've been focused on that and scaling that up. I mean, again, part of our thinking here, Josh, is that consistent with our move into more high-acuity ambulatory surgical work, de novos also represent a significant value shift in markets, right?
Because, usually, what you're doing is you're building from the ground up. You're moving things into a lower-cost setting. It's value for the consumers and payers in the markets to be focused on de novos, in addition to everything else that we may be doing to grow the portfolio and expand the high-acuity services. So that -- it's part of our value strategy there. And maybe that's why you're seeing more of it from the de novo side.
In terms of the competitive landscape, no, I don't think the competitive landscape has changed. I mean, the easiest way to assess the competitive landscape is to just count the center counts across different organizations. And some are scaling better than others. And that probably, more than anything, reflects competitive -- the output of whatever competitive intensity exists.
We've been pretty pleased with our ability to scale, win competitive situations and processes where we want them, and maintain high-quality high-profit margin centers. And we always assess that pipeline every year. The pipeline still looks good for doing that.

Josh Raskin

That's helpful. Is it fair to assume that the de novo long-term returns on capital are higher?

Saumya Sutaria

Yes, of course. Yes. Because again, the -- it's not like building an acute care facility, right? The building costs are low. It's a shorter timeframe. Once the partnership is syndicated, there's work upfront in syndicating the partnership that takes time. But that's not a capital-intensive activity.
Look, I think at the start of this, Pito pointed out one of the big changes in the organization around the generation of free cash flow. We also focus on measuring and following our overall return on invested capital within the organization.
And obviously, the more we shift into this ambulatory segment, the more that gets better. And obviously, the more we do de novos, we see that that gets better in terms of what we're doing in the business when we're deploying our cash. So yeah, you're absolutely picking up on what we're doing for the right reasons.

Josh Raskin

Thanks.

Operator

Matthew Gillmor, KeyBanc Capital Markets.

Matthew Gillmor

Hey, thanks. I wanted to follow up on the cost management and efficiency comments. The company has clearly made a lot of progress the last few years, and you noted the SWB and contract labor metrics. As you look ahead, are there any areas of particular focus that are going to continue to drive efficiency in 2025 and beyond that you'd highlight for us?

Saumya Sutaria

Sure. I mean -- I think that the cost management agenda doesn't change in terms of managing labor, managing supplies, managing purchase services, active vendor consolidation, activities, scaling our service lines in which we've got a cost structure that we're comfortable with. Obviously, just that scale creates opportunity.
I've said, in the acute care segment, I've said all along, we're really pleased with the improvements that we've made in so many of the metrics from the standpoint of cost, labor, overhead, supplies, purchase services, relative to our peer set in the industry. Obviously, we always continue to note that an area that we can improve is our asset utilization. And that's obviously in comparison to what we look at as kind of the gold standard out there.
So that's really an area that we're continuing to work on as we expand capacity and build volumes into some of the facilities that we took capacity offline during the pandemic from an efficiency standpoint. Our global business center has contributed significantly to our cost savings. If you think about the last four, five years the journey we've been on, of course, there's obvious unit cost savings that you see on an immediate basis.
But there's a lot of cash flow that goes into actually restructuring and building and scaling that enterprise. And what might have started with kind of commodity work in certain areas of finance or accounts receivable has expanded to 10, 12 different service lines that we are now running effectively in the global business center clinical areas, clinical analytics, physician credentialing a variety of things.
And that's an important part of our efficiency agenda as we look forward as well. And it's -- now that it's, obviously, well passed breakeven cash flow, those savings materially contribute to what we're doing.

Matthew Gillmor

Got it. Very helpful. Thank you.

Operator

Ben Hendrix, RBC Capital Markets.

Mike Murray

Hi, this is Mike Murray, on for Ben. Thanks for taking my question. So ASC total joint procedures grew nicely in 2024. I wanted to hear your expectations for growth in 2025 and beyond.
And then cardiology procedures have been the latest slated to drive material growth in ASCs. Can you discuss any early progress there, and when do you see these procedures really accelerating? Thanks.

Saumya Sutaria

Yeah, hey, it's Saum. We -- obviously, we anticipate continuing to focus on our orthopedics line of business going forward. We're not going to guide service line level volumes from that perspective. But we still think, obviously, there's a tailwind in ambulatory surgical growth from an orthopedic standpoint. And that's both the stuff we're doing today and expansion of the procedure set that could be done safely in ASC.
Same with cardiac, I mean, as I've said all along, the opportunity in a wide variety of cardiovascular procedures is there. I've always been clear that I think that that opportunity will proceed more slowly than people anticipate because of important patient safety considerations and payer mix considerations. And also, the CapEx required to build a cardiac center is very different than building other types of ASCs given the equipment that you have to have in there.
So the upfront investment for the physician partners and other things is much higher with potentially lower margin assets. And so from economic reasons and patient safety reasons, I think this market will evolve, but I think it will evolve slower than people like to think. And we'll, obviously, be participants in that as we are today. But we're also -- we're not going to try to rush it and sacrifice patient safety and quality in that regard.

Mike Murray

That's helpful. Thank you.

Operator

This concludes today's conference. You may disconnect your lines at this time, and we thank you for your participation.