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LifePoint Hospitals, Inc. (LPNT)

February 26, 2013 1:30 pm ET

Executives

William F. Carpenter - Chairman, Chief Executive Officer and Chairman of Quality Committee

Jeffrey S. Sherman - Chief Financial Officer and Executive Vice President

Analysts

Gary P. Taylor - Citigroup Inc, Research Division

Gary P. Taylor - Citigroup Inc, Research Division

Good afternoon, my pleasure to introduce LifePoint Hospitals. I've somehow misplaced my description of the company, but obviously, really the largest pure-play -- what I'd say still call pure-play rural hospital company that's out there. We have Bill Carpenter, the CEO and Chairman; and Jeff Sherman, the Chief Financial Officer, with us today. So gentlemen, thanks for being here.

William F. Carpenter

Yes.

Gary P. Taylor - Citigroup Inc, Research Division

Kind of first question. I've just been asking everyone's view on -- this theme of our confidence is the value imperative and as a health care team, our thesis is over the next 5 to 10 years, increasingly payers, commercial and government payers, are going to want more value over what they're buying as opposed to paying for volume today, moving to some sort of definition of value. And so the question is, are you seeing any of that yet in your market? What do you think you need to do over the next 5, 10 years to position LifePoint for a change in how payers may choose to pay for what it is they're purchasing from you?

William F. Carpenter

So we look at the value proposition in this way, Gary. We are going to be paid less in the future for the services that we provide, and we're going to be judged on the basis of the clinical outcomes that we deliver. So the expectation is -- our view of the expectation of pay for performance is clinical outcome improvement and produce reimbursement. So we are, in fact, positioning the company in order to be able to accomplish both of those things. On the improved clinical outcome front, we've always been proud of the quality of care that we provide in the communities where we're located. But in addition to that, we have entered into our partnership with Duke University, for instance, in order to be able to bring top 10 academic health care to small community hospitals across the country. We're also 1 of 26 entities that received a Hospital Engagement Network contract. We're the only full private company to be the recipient of one of these Hospital Engagement Network contracts, which are designed to find ways to reduce readmission and to find ways to reduce the harm events that occur in hospitals, both of which are things that go straight to the definition of value that I see as being improving clinical outcomes. So we're working hard on this thing. At the same time, we are working hard to find ways to take cost out of the system. And we've announced recently our Parallon initiative, whereby we are outsourcing certain back-office functions to Parallon, with a view that their scale and their expertise in that area should allow them to, quite frankly, do a better job at those discrete areas, even though we would be able to do it in 57 different back-office operations across the country.

Jeffrey S. Sherman

And I would add to that, Gary, on the contacting side, we're certainly seeing that Medicare is leading the charge with hospital readmission penalties and hospital-acquired conditions, a carrot and a stick approach. So we're seeing -- that's kind of the early signs for that. We do not have a lot in our current commercial managed care contracts related to quality metrics, but we see that is going to evolve. In general, we expect many of these changes to come and more risk bearing, more different types reimbursement structures to come later to our more rural communities than the urban markets. For instance, we don't still today have any capitation agreements. We're not taking full risk in any of our markets today. So we see those types of changes potentially coming slower to rural communities. We are preparing for that. We're looking at ways to organize and work with our physicians more closely in our markets. We're employing more physicians as well. So we're taking, we believe, the necessary steps to prepare for whatever the ultimate -- whatever these ultimate reimbursement changes plan out over time. But we expect some of those changes to come slower to our community, just by virtue of the physician infrastructure, physician relationships we have and the fact that you don't have those more advanced payment methodologies in our markets today.

Gary P. Taylor - Citigroup Inc, Research Division

If I think back over the last couple of decades, back in late 80s, early 90s, where we're seeing capitation growth, the PPM growth, the managed care industry consolidating and putting a lot of pressure on urban providers, really, that was kind of the time period where the HMA and the communities of LifePoint have kind of -- the end of loan or differentiated rural model actually performed pretty well. So through that time period, you would look back, you were still relatively isolated from more progressive payment methodologies historically as well, right?

William F. Carpenter

I think that's accurate and not a lot has changed over that period of time, but we will see. I think more new and different payment methodologies, bundled payments moving to more pay for performance or clinical outcome, how do we get more efficient, provide better clinical outcomes. Coming in, I think we're preparing -- we think we're doing the things we need to prepare for that, we just don't think that's going to happen in the near term, in the next few years. But we are preparing for that. We think, eventually, it will come over time.

Gary P. Taylor - Citigroup Inc, Research Division

So even if some of the payment model changes move much slower into some of the smaller rural markets, you are seeing the opportunities and uncertainties from reform having a lot of impact on physicians and physicians' willingness to be employed or -- certainly by hospitals, seeing a lot of hospital employment and less willingness to be out there paying a shingle and be a part of the practice. And that has impacted, I think, some of your physician strategies over the last couple of years. And in fact, your employment of physicians has increased, and like most hospital operators, there's losses that are incurred as you operate those. So can we talk a little bit about, over the next 2 to 3 years after this pretty substantial buildup of physician employment, what are your expectations there over the next 2 or 3 years?

William F. Carpenter

I think our expectation is we're going to continue to see physician employment increase. We've talked about our losses from operating the practice. This is just the professional fee side of the business, both taking into account any of the other volume in the hospital. Those losses have increased, but very consistent with the number of our employed physicians increase. So in fact, the physicians we've employed for over a 12- to 18-month period, we continue to see improvement in those practices, so our losses are proportional to more doctors coming in. We think, for some of the reasons you outlined, the complexity of managing a sole practition -- practice today, increasingly, physicians are looking at employment as an option. They're seeking for quality of life or work balance issue for dealing with the complexities of the business. So I think we're seeing that. We have built the physician practice management infrastructure in the company to help manage that. We've gone through a standardized AR, IT platform for employed physicians, so we think that will help improve productivity over time. But we expect that to continue. We expect to see more physicians seeking employment, but it still represents less than 15% of our total physicians on staff. So it's still a relatively small percentage, but we are seeing more of our physician recruitment types of arrangements coming through employment contracts.

Jeffrey S. Sherman

So employment is one thing, physician engagement is an entire strategic focus for us. We have to get closer aligned with our physicians in order to be able to provide the care that is needed in our communities. And so we have been reaching out to our physicians in a more intentional way in order to be more focused on what it is that they need in order to be successful, because we believe that physician engagement is in fact helping physicians improve the clinical outcomes for their patients because at the end of the day, that's what they really want. They really want their patients to receive the best quality care, and they need the opportunity to be successful, financially successful. And what we're hearing from physicians across the country, pretty much uniformly across the country, is they need help on contracting, they need help on managing the practice and they need help on their IT connectivity. Those are the 3 things that we have heard over and over and over again in meetings and focus groups and one-on-one conversations that I'm having with physicians around the country, physician leaders around the country. And so we are putting in place -- we are working on some of the things that Jeff has discussed, but we are looking for opportunities, ways that the hospital can help those physician leaders, those physicians answer those questions. Where do we have the ability to do that? The physician engagement aspect, whether or not employed, becomes a real opportunity for the hospital to accomplish some things that, in the past, physicians and hospitals have been a little bit more at odds with one another. I think we'll be able to address a lot of that and see some real improvement.

Gary P. Taylor - Citigroup Inc, Research Division

And it's been my observation over the last 10 or 20 years that I kind of look at the hospital industry as a barbell and say there's a couple of places on the barbell where we could see really good margins and returns. One end of the barbell is bigger market with big share driving commercial rate because of that share, and the other is the need historically had higher-than-average margins if you're in smaller rural markets. And you have more percentage-based reimbursement, you have less aggressive managed care, you have less physician and outpatient competition as a market. And so I guess, the question is yes, over the last few years, you faced as much industry headwinds as most of the hospitals. Is it this physician engagement piece that's added the most complexity to your end of the barbell over the last few years? Would you say, no, it's really been more just straight out government reimbursement cuts and RAC scrutiny? And is it physician complexity that's changing and more engagement is needed and more employment, more outpatient competition, more in-office movement? Or is it the government piece? Or are we just talking about 2 of the biggest things that are...

William F. Carpenter

Well, those are 2 of the biggest things. So physician employment is a big comp item that you didn't see 5 years ago to the extent we have it today. So remember, when we employ physicians, that's a very high-end employee. And when we employ a physician, we're also employing the office staff. So those nurses, receptionists, other people who work in the practice, are now our employees, as well as historically, those that have been the employees of the physician. So that's one piece of it. And Jeff can fill in some of that. The other thing that you didn't mention in addition to -- you did mention reimbursement and the pressure of that and RAC and all the rest. And we think our rural hospitals may be a little more susceptible to that because most of RAC, as you know, have been focused on the one-day stay, observation-type visit.

Jeffrey S. Sherman

Lower intensity.

William F. Carpenter

Lower intensity cases that you would expect to find more of in a rural-type hospital. But the one other thing I want to put out on the table and then we can talk a little bit more about it is it's just the general IT spend. So it's been a significant spend over the past few years to get ready. It's not just the capital spend. It's a spend that has been sort of ramping up over the last couple of years to get ready for meaningful use.

Gary P. Taylor - Citigroup Inc, Research Division

So I would add -- would just add a few other thoughts. So on a same-store basis, our margins held between '10 and '11, we did see some declines in 2012 for the reasons you talked about. And then we've had acquisitions. So we've acquired a fair amount of revenue over the last couple of years at significantly lower margins. So we only got the total overall margin of the company bringing on these lower margin facilities that have had an impact. So from a margin perspective, I would say the acquisition -- bringing our lower margin acquisitions that will improve over time and physician employment have probably been 2 of the biggest impactors. We've seen reimbursement pressure and obviously, getting less from Medicare or less from Medicaid have hurt margins as well. But the 2 most impactful things have been acquiring lower margins facilities and physician employment. But we still get a fair amount of our business from the outpatient side. But to your point, we continue to get good reimbursement on the outpatient side. That also helps from the margin side. So overall, our margins continue to compare relatively favorably. We've made a lot of investments in what we consider to be this employment model, which has a long-term return. And as Bill pointed out, we've made significant capital investments, most recently on the IT front, with a lot of upfront capital costs and not much bottom line performance. But we'll start to see recovery of those investments in '13, '14 and '15, as the meaningful use dollars ramp up meaningfully for us.

Gary P. Taylor - Citigroup Inc, Research Division

Got it. One of the things that I just have struggled understanding, I'll put you on the side and ask you this, is that we look at, obviously, short-stay pressure, RAC audits, all this over the last few years, has been a pressure throughout the industry. When we look at your comparative statistics, we'd say LifePoint has the lowest short-stay percentage, I think I'm right as I'm recalling my words, than any of the publicly traded guys. When we look at some of the coding, intensity of coding, what looks to be some of the lowest, most conservative intensity of coding of any of the publicly traded guys, what I'm saying is everything -- it looks like you leave money on the table when you're so conservative, which isn't a bad thing for investors to absorb. So I've just been surprised that, I guess, some of the magnitude of some of the RAC pressure because I'd say, look, I could lay out the whole industry and I could pick a handful of other companies that, to me, might look like more obvious targets and yet here is LifePoint at the low end that's seeing still a lot of movement from short-stay observations. So any comments on how that makes sense?

Jeffrey S. Sherman

Yes, we have talked about one-day stays and observation visits, probably longer than most of the other companies. And so when the RAC audits came out, they told us they were going to focus on short stay, so we were expecting that and I think we do a lot of education around that in our hospitals. And I think we saw an impact from that, probably earlier than others. But the actual RAC, and I'm talking about 2009, 2010 timeframe now, the RAC audits actually didn't start until 2011, in a meaningful way, and really ramped up in 2012. So I think there's a lot of moving parts there. We've made a lot of investments about adding internal resources and external resources to get it right, to get patients in the right clinical setting. I think our goal is to document what we do and then get paid for what we document in our facilities. So I think as we've talked about the RAC audit impact, what was a tailwind in 2012, we expect it's going to be at a similar level in 2013. But keep in mind, it's not a static. The whole issue is not static. InterQual criteria changes over time. This is not a static thing, which is the same every year. So I think we've made a lot of investment. And also, keep in mind, the RAC audits are also going back. I mean, they're looking at sub 3 years old as well. So I think there's potential. There's a lag factor in what has been looked at on the RAC side as well. So to the extent you've made improvements during that time, you may not have seen it yet in any of the outcomes. So I think a lot of moving parts. We're committed to getting patients in the right clinical setting. We're utilizing more technology. We're moving towards a computerized InterQual real-time system in 2013 to further help us do more real-time auditing and review of our InterQual placements. So I think those are the observations that I would give you. We're not expecting it to be incrementally more negative in 2013. But the RAC audit, I would also say, I think, focused on what they thought was the biggest opportunity to begin with, but I think that's part of it as well. And I think that's what we've started with.

William F. Carpenter

I do think there's lower intensity service than you would expect to see in our hospitals more often than you would see in a more urban, perhaps, acute kind of setting.

Jeffrey S. Sherman

And we've compared ourselves with the rural providers, and I think we're -- we tend to be pretty consistently in line with other providers in rural communities from that standpoint.

William F. Carpenter

It does seem like we talk about it more, and I don't know why that is. It's something that we have talked about longer certainly than others seem to have. But you know what, I'm going to be with our operators. Jeff and I will both be with all of our operators at the end of this week in a big meeting. And I'm going to lead that meeting. The first thing you're going to hear out of that meeting is going to be about compliance. It's going to be about doing the right thing and making sure that we get it right, do everything we can to get it right. We're never going to get it right all the time, and we know that. And -- but it's just important for our company and for our operators to understand that our expectation is get it right. And when we do training on things and when we -- when the RAC say we're going to focus on what they say is we do training on that. It is not inconsistent with my expectations that we're going to stay -- that we're affect behavior in that regard. We just don't want to go -- we're going to get it right. It's sort of like paying your taxes. You know what, you ought to pay the right amount, you ought not pay too much. You certainly ought not pay too low. So that's the way we think about it.

Gary P. Taylor - Citigroup Inc, Research Division

Just want to touch on the IT spending a little bit. A couple of questions. A lot of this is shorter useful life, and that's why you've called out, I guess, kind of, disproportionate may not be the right word, but the...

Jeffrey S. Sherman

Much higher depreciation.

Gary P. Taylor - Citigroup Inc, Research Division

Yes, having an impact on your D&A. Have you identified a year where that peaks and rolls off? Or if this is mostly 7-year stuff and you're a couple of years into it, are we still 5 years from when you see some of this roll off, some of this...

Jeffrey S. Sherman

Yes, I would say it's lower. It's probably more a 5-year depreciation spend, and we have said the peak years of capital investment are going to be -- were '11, '12 and '13. And so that will -- with the IT side, we will peak out between '12 and '13 in terms of the capital investments that we are making and have made for meaningful use. And you'll see that drop off, but you should see depreciation over time roll off accordingly with that, with anywhere between 5, 6 year useful life versus a 7 to 15 average useful life on kind of non-IT equipment capital investment.

Gary P. Taylor - Citigroup Inc, Research Division

And if we look at kind of a 5- or 6-year window that we might be 2 or 3 years into in terms of your journey towards Stage III meaningful use, I think you're still comfortable that high-tech income, the sort of income that comes back to LifePoint, exceeds the capital outlay. What about if we look at a 5-year window of capital outlay plus the operating costs, are you going to get as much back as you spend? Or ultimately, over that 5- or 6-year window, with a net negative?

Jeffrey S. Sherman

I think, overall, it probably comes out pretty close to a wash, that we're going to get our capital back in terms of return for meaningful use. But we'll have ongoing benefit from that. I think we'll see some softer benefits in terms of clinical integration, in terms of pharmaceutical interactions, et cetera, that we think we'll get the benefit on. Much harder to attach an ROI on that with any confidence, which is why a lot of those investments probably haven't been made historically. So having the incentive dollars to help push that along was meaningful for us and I think the rest of the industry.

Gary P. Taylor - Citigroup Inc, Research Division

Kind of the big topic of the day over the last 6 months, over the last 12 months, obviously, trying to think about the impact of Obamacare on hospitals, and they're probably proud that I have $0.25 into this before I brought it up, so I'm trying to talk about other things. I think you've answered a lot of questions about it today. But I guess, kind of trying to ask everybody similar type of questions to be able to put the responses into context. But what do you see as the couple biggest uncertainties as we stand here today on how Obamacare is going to impact you? And where do you see as the next things we're going to get some visibility on? And it may not be the 2 most uncertain things, but what's most uncertain, what's next in terms of visibility on some of the important data points for you?

William F. Carpenter

Well, there are a lot of assumptions that people are making with respect to the implementation of Obamacare. I guess, the President now calls it Obamacare, so it's PC to call it Obamacare. So -- and I think those are what happens with these changes. What -- how do the employers feel with providing -- continuing to provide commercial coverage? And then the exchanges, quite frankly, are completely up in the air. The rules have not been ready, or at least have not been public. So I think those are the 2 things that continue to be the biggest sort of wildcards in the modeling. What are exchanges that -- which is part of the whole rollout with respect to the changes. I think there's becoming much more certainty around Medicaid expansion. Certainly, the adoption by some conservative governors of Medicaid expansion is political cover, if you will, to some other states. And I think you'll see, in our view, most states come along in that regard. Those are the 2 biggest uncertainties that we see in that.

Jeffrey S. Sherman

So we have been asked a lot of questions about it. I think as we view it, when you look at our markets being the only hospital in the vast majority of the markets we serve, we are treating and seeing all of the uninsured patients in our market today. So I think we're positioned well to benefit from expanded coverage from reform. We're obviously having to give up future Medicare and Medicaid reimbursement to get that coverage. But we think we're positioned well to have discussions with pricing on the exchanges and positioned well to benefit from that expanded coverage because there's no other place for uninsured patients to go in our market today. There's not charity hospitals or county imaging facilities in our markets. So we are receiving the uninsured patients today for getting some incremental form of reimbursement for those patients should help us. We have to contract that against what we're giving up for Medicare and Medicaid reimbursement, and they'll point it out, what's the timing on exchange rollout, the timing on adoption by patients that don't qualify for Medicaid. So for Medicaid expansion, if the state expands, that's pretty easy for us. We're already doing eligibility screening and imaging program screening at every one of our hospitals every day today. So the Medicaid expansion side of this is really just continuing to do more of what we're doing today. We're going to have to find ways to look at the exchanges and be helpful and I think be proactive in how we help patients that don't qualify for Medicaid in our communities, see the benefit and the value of the exchange product and how do we work and potentially even with the payers to help get the word out in our communities that this is something that's available and something that's helpful to patients, and we can help lead that.

Gary P. Taylor - Citigroup Inc, Research Division

When you look at the totality of ObamaCare, are the critical assumptions in your mind still so unknown that you can't opine on how it impacts life or can you look at it and say, "Reasonable assumptions would suggest more coverage is going to be good for us despite the fact that we have reimbursement cuts, et cetera, and it's a net positive."

Jeffrey S. Sherman

We have said and continue to believe it's going to be a net positive for LifePoint over time. I think to your point, we're going to have to get more clarity to narrow the range of outcome to put more definitive numbers along what does this really mean. So I think as we see states make decisions over the next 6 to 9 months, and there's no deadline for a state to opt in or opt out, that's one important curved line point. I think the exchange pricing, with plans having to be ready to go for open enrollment October 1 for January 1 start date, I think getting clarity on exchange pricing is another important one. And the piece we haven't talked about yet is what happens with utilization. So I think it's our expectation that you would see an increase in utilization. Again, other states that have gone through this have seen this. But at what rate and how to model that, there's a lot of variables. But as we have looked at ranges of outcome, we believe it's going to be a net positive for LifePoint. And as we get more clarity around some of these independent variables, we'll look to provide more guidance around it.

Gary P. Taylor - Citigroup Inc, Research Division

My last question and then we'll take a few questions from the audience. On its last call, HCA kind of raised this issue that part of Obamacare, as you're going to see some reductions and DSH paying that helps fund the subsidies and the costs of expanding the program. But even before we get to the Obamacare cuts, they kind of have to define what is uncomplicated care to decide how it's reallocated. There's been a proposal to sort of redefine how DSH payments are allocated that the proposal, at least, does not include uninsured discounts, which a lot of your peer, public peers have given a lot of discounts and has caused some consternation. LifePoint hasn't been a big discounter. If you look at your total uncompensated care, it's probably the lowest of the publicly traded guys. So you have perhaps the least risk or least impact if that proposal takes shape. Have you guys looked at it, concerned about it, thought much about it? Any comments on that?

Jeffrey S. Sherman

Yes, I mean, I think we've certainly looked at it. We haven't taken a public position yet on this specific mechanic. I think the overall, I think, as you stand back and look at it, there should be an ability to get to some uniform agreement on what uncompensated care is that the industry, I think, could and would support. So I think we'll continue to look at it from that standpoint. But we don't have as much uninsured discounts, to your point, as some of the other companies. But I think we'll continue to look at it and continue to study it, but haven't really made any other pronouncements at this point about our views on it. But I think there needs to be some reasonable way to define uncompensated care that can get the support of the industry.

Gary P. Taylor - Citigroup Inc, Research Division

Got it. Any questions from the audience? Don't be shy. There's one up here.

Unknown Analyst

I know the history of the industry tells you that your markets are going to probably be affected later in the cycle of moving to accountable care and new payment models. Do you think it's going to be different this time? Why do you feel that confident that it's going to remain in that kind of old mode?

Jeffrey S. Sherman

I don't think we said it's going to remain in old mode. I think our view is that the change is going to happen quicker and faster in the urban markets. I think the benefit for us for that is we'll be able to study that, look at that, see what's been successful or not. I think secondly, for us, back to my earlier point, most of our markets have 1 or 2 men or women physician groups. We don't have a lot of large integrated medical groups that have managed the continuum of care. That's one of the reasons why we haven't seen -- also haven't seen capitation migrate into rural markets. You have the hospital piece, but you also have to have the physician piece organized in a way to take and manage risk. And to my earlier point, we are looking at how do we align physicians differently, how do we help them get together in different types of models. It might be an IPA type of model to look at different forms of reimbursement. So I think those are a couple of factors, which still haven't taken place yet today. But employing more physicians will allow us, regardless of which direction that goes that will allow us, I think, to react quickly. So we're not sitting back and waiting for all of this to happen. We're taking a practice that -- and I think we will also look at a couple of markets that we can price them, experiments, do some trials with that may make sense for us. Our recent acquisition in Marquette in the upper Peninsula of Michigan, we also have an ownership interest in an insurance company in that market. So I think we'll have some ability to try some things, see some things that are working on other markets and we'll have time. We didn't just rush out though and form 56 accountable care organizations. We think we'll have some time, but we're not just sitting around waiting for it to come to us. We're taking proactive steps to prepare.

William F. Carpenter

But as soon as Obamacare was enacted, we had a lot -- a flurry of activity among doctors and physicians in our markets and everybody was running around, trying to figure out what they were going to do in their markets. And from our hospital support center, from our -- we set the leadership position and said, "Look, let's slow down here. Let's look at history." So history is proving itself out again. We stay in close touch with our physicians in our communities. We're not seeing narrow network penetration at this moment, and our communities, we're watching it very carefully to make sure how these things go. And we do think that just given the nature of the market share that we have as a result of being the only hospital that's there, that we're in a good position.

Gary P. Taylor - Citigroup Inc, Research Division

Any other questions? So if not, gentlemen, thanks very much.

Jeffrey S. Sherman

Great. Thank you.

William F. Carpenter

Thank you. Thanks for having us.

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