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Executives

Trevor Fetter – President and Chief Executive Officer

Steve Newman – Chief Operating Officer

Biggs Porter – Chief Financial Officer

Analysts

Ralph Giacobbe – Credit Suisse

Adam Feinstein – Barclays Capital

Sheryl Skolnick – CRT Capital Group

Shelley Gnall – Goldman Sachs

Darren Lehrich – Deutsche Bank

Whit Mayo – Robert Baird

Gary Taylor – Citigroup

Tenet Healthcare Corporation (THC) Q1 2009 Earnings Call May 5, 2009 10:00 AM ET

Operator

Good morning and welcome to the Tenet Healthcare’s Conference Call for the First Quarter, Ended March 31, 2009. This call is being recorded by Tenet, and will be available on replay. A set of slides has been posted to the Tenet website, to which the management will refer during this call. Tenet's management will be making forward-looking statements on this call. These statements are based on management's current expectations and are subject to risks and uncertainties that may cause those forward-looking statements to be materially incorrect. Management cautions you not to rely on and makes no promises to update any of the forward-looking statements.

Management will be referring to certain financial measures, including adjusted EBITDA, which are not calculated in accordance with generally accepted accounting principles, or GAAP. Management recommends that you focus on the GAAP numbers as the best indicator of financial performance. During the question-and-answer portion of this call, callers are requested to limit themselves to one question, and one follow-up question.

At this time, I will turn the call over to, Trevor Fetter, President and CEO. Mr. Fetter, please proceed.

Trevor Fetter

Thank you, and good morning everyone. We are going to keep our opening remarks fairly brief this morning. As I think our first quarter results speak for themselves. I’m very pleased with the 28% growth in adjusted EBITDA, and the very strong cash flow that we generated. Not only that we improved cash from operations. We also carefully controlled capital expenditures and succeeded in completing the sale of USC University Hospital.

We also closed the bond exchange transactions in the quarter. So, between operations the sale of USC and the bond exchange I feel our balance sheet is in far stronger shape, then it was as we entered 2009.

Now I’ll be the last person to declare victory as our volume growth turned negative after improving steadily during the course of 2008, and with the stock price where it is I’m far from satisfied, but I am pleased with many of the trends.

Our first quarter demonstrates that employees at every level of the company have embraced cost reduction in the face of the tough economy and mildly shrinking volumes. The evidence of this is quite apparent with the growth in same hospital controllable operating expenses for adjusted patient day of only 1.2%. If you prefer to look at it for adjusted admission controllable cost were actually down 0.7%. This is the result of a number of initiatives. We talked about our efforts to remove cost from corporate overhead, but there are other initiatives as well throughout the organization, and into very granular levels of detail.

One aspect of this week economy is that enables everyone to appreciate and support cost reduction efforts. The quality initiative we launched in 2003 once again delivered results with a $19 million or 48% reduction in malpractice expense. This is in addition to all the ancillary benefits to patient safety to physician satisfaction and to our reputation that sustained increases in quality have brought.

One of the things we look forward to sharing with during our June 2nd Investor Day is our new Medicare profitability initiative. Steve will make a few comments on at this morning, but for a more detailed explanation you want to join us on the second. We launched this initiative because Medicare and managed Medicare represent our fastest growing patient segments. And the demographic trends in the U.S. will continue to drive growth in eligible population beginning in just three years and lasting for the next decade the over 65 population will grow at more than double the annual rate at which it grew in the last 10 years, also the significant changes in healthcare finance that are likely to be proposed by the Obama administration may drive even more growth in programs that’s look Medicare.

I would imagine that the biggest question in your minds just to what extent the first quarter performance is sustainable. Biggs will address that question in his review of our 2009 outlook. At a very high level the sustainability question come down to a handful of fundamental issues. Cost control, bad debt expense trends and patients volumes and mix.

I think the operating savings that we’ve captured are largely sustainable. For several years leading out to the current economic downturn we had excellent performance and controlling rate of growth of cost. We’ve stepped up our efforts and at all levels of the organization we are driving for new cost savings.

The tough economy and as the silver lining in that our labor force is more stable, more productive and eager to work more hours. Due to our prior efforts and helped by the tough economy in the first quarter turnover was down 22% year-over-year, contract labor cost were down 33% and overtime was down 16%.

The issue of bad debt expense presents a greater level of uncertainty, while Tenet captured some solid benefits here by getting out in front of this problem very early, it's very hard to predict how much pressure we’ll see on this line item, if unemployment continues to rise.

As you would expect we’ve experienced pressure on our collection rates from patients, but we’ve significantly offset that slippage by collecting money sooner.

Finally, I’m pleased that volumes held up as well as they did in the first quarter. Adjusting for the impact of leap year total admissions were relatively flat. In the midst of a severe economic downturn I think this demonstrates that our services are largely non discretionary. And flue volumes were virtually non-existence in this year’s first quarter. Our stable volumes are even more reassuring.

I’m particularly pleased with the growth that we generated in paying outpatient volumes and surgeries, which were up 2.3% and 2.6% respectively. The volume picture in April was mixed. Total same hospital admissions, outpatient visits and paying admissions trended slightly better than in the first quarter, but commercial impatient admissions trended lower declining by 6.8% in the month. A real bright spot is outpatient visits both in total and commercial, which continue to show improving trends. We’ll update you on Q2 volumes at our Investor Day when we’ll be two months into the quarter.

With that I will now turn the call over to Steve Newman for some comments on our key operating initiatives. Steve?

Steve Newman

Thank you Trevor and good morning everyone I want to focus my comments this morning on two of our key operating initiatives. Then I want to describe our newest initiative the Medicare profitability initiative or MPI. This new initiative is focused on driving down variable cost at the point of care and improving clinical outcomes.

I’ll start with our physician requirement activities. Net of attrition, we added a 167 physicians to our active medical staffs in the first quarter. While this growth is a little less than one quarter of our goal for 2009 of 1000 net new physicians. Let me remind you that the requirement process is seasonally driven, the first quarter tends to be light, while the third quarter is usually the most fruitful. This is because residents and fellows finish their training in the May, June timeframe and then move to establish new practices. I’m pleased with our first quarter progress in ’09 and want to reconfirm our target of net growth of 1000 active staff physician again this year.

Of course the expansion of our medical staffs is not an end in itself. We see these relationship as a powerful mechanism to continue volume growth. Slide 12, 13 relate the net expansion of our medical staff over the past two years to our recent volume growth. These two slides show our first quarter total and commercial admissions and outpatient visits, from our classes of 2007 and 2008.

In the first quarter, we averaged almost seven admissions from each member of the class of 2000, with 22% of these admissions being commercial patients and the average 46 outpatient visits from each of these physicians with 31% of these outpatient referrals being commercial.

The referral patterns from the class of 2008 are only slightly lower, reflecting the less mature status of these relationships however, they remain ahead of the growth from the class of 2007, at the same stage of development. These data demonstrate that our relationships with these new physicians are continuing to mature in a very positive fashion. We believe the successful expansion of our active medical staff was one factor in a very strong 2.6% increase, we saw in surgeries in the first quarter.

We continue to add staff, business, intelligence and refinements such as expanded educational offerings to our physician relationship program.

Next I want draw your attention to slides 14 and 15, which show our admission growth in total paying patients both inside and outside of TGI service lines.

First, in comparison to Q1 ’08, we generated stable volumes in total paying patients in the quarter, after adjusting for leap year. Second, we saw a total paying patients in the TGI service lines, growing faster than total paying patients in the non-TGI service lines. However, our commercial managed care volumes in the quarter were stronger in the non-TGI service lines, then in the 7 TGI service lines, we’ve cited in previous calls.

After digging into this data on commercial volumes, we believe the reason for the lower commercial growth and our TGI service lines is because patients are deferring elective procedures in the weak economy. It is important to note that from a pricing perspective, although we did not get lift from the TGI service lines in the quarter we benefited from an offsetting positive mix in commercial patients within the non-TGI services lines.

Now I want to turn to my new topic for this morning’s discussion. Our new Medicare Profitability Initiative or MPI. We have launched this initiative to address profitability challenges resulting from the growing percentage of our volumes, which receive Medicare-style reimbursement. This reimbursement trend is likely to accelerate and must be addressed. But in fact, the effort we are focusing here will impact our profitability across all payer categories. The primary driver here is the identification of best practices in our highly efficient hospitals and introducing them to very facility in our company.

We’ll be focusing on the customized list of five DRGs, for each hospital, where we find a substantial opportunity to drive down variable costs. I'm convinced that the experience we gained in implemnting our Performance Management Innovation Program gives us the skill set necessary to be successful in capturing these cost savings.

A critical piece of this initiative is directed to working with our physicians to modify care delivery. Together we will provide improved clinical outcomes and enhanced resource utilization efficiency. This is the data driven exercise which we believe, we are well positioned to address. We are very excited about the prospects for incremental EBITDA margin expansion from MPI. I have only scratched the surface this morning. If you want to learn more, please join us on June 2, for our investor day, when we will be able to devote much more time to exploring this inattentive.

Now let me turn the floor over to Biggs Porter Tenet’s CFO. Biggs.

Biggs Porter

Thank you, Steve and good morning everyone. I’ll touch with the few items, where the reinforcement or explanation. Summarizing briefly on volumes. We are very pleased with how the other quarter progressed with stable trends especially after normalizing for the leap year effects.

Commercial admissions declined by 2% after the leap year adjustment. You will recall that we disclosed in our fourth quarter call that commercial admissions had declined by 3.1% through roughly the first half of the quarter. Since the final decline was 2%. It should be apparent to you, the commercial admissions strengthened in the second half of the quarter.

April commercial admission declined with Easter likely having effect, the commercial visit were stable in April. The variance between commercial inpatients admission and outpatient visit trends in April, makes it difficult to correlate the statistics for a single month into any meaningful conclusion.

Having said all of that based on the first four months of the year. We are still comfortable with using an assumption of approximately 3% commercial volume loss for the year, as a starting point for our EBITDA walk forward. Conversely we still are going to see growth in uninsured volumes but continue to hold on the conservatism and we sated in February have an assumed growth in uninsured for the year of approximately 5%.

Total revenues grew by 3.6% on a same hospital basis. This growth included $11 million in favorable costs report adjustments. For those of you who are attempting to back this $11 million out the first quarter earnings I want to draw your attention to slide 19, which shows our history of quarterly cost report adjustments and makes it clear the $11 million in favorable adjustments are not a particularly unusual event and are recently consistent with our historical pattern.

The most powerful driver of margin expansion in the quarter was incremental cost efficiencies. To place this in the context, our expectations for the full year are 2009 outlook of $150 million and savings from our cost initiatives has been increased to approximately $180 million. The decline in malpractice expenses made an important contribution to the first quarter’s costs net metrics and contributes to the increase in our projected cost savings for the year.

I don’t want to get into providing line item guidance on the components of our operating expenses but while we don’t believe the $21 million in first quarter malpractice expense is a level we can sustain. We do expect continuing favorable year-over-year variances in malpractice for the remainder of the year.

Bad debt came in with a favorable variance to our expectation based primarily on reduced uninsured revenues. We collected more point of service but nonetheless there was a decline in our combined balance after and self pay collection rate. The lower uninsured admissions and revenues for the quarter continue to trend in which we experience results counter to what would be expected in a recession. This maybe attributable to our right care, right place Medicaid eligibility initiatives but other factors are likely involved is well.

Despite this welcome Q1 performance we intend to retain a cautionary stands relative to our bad outlook. We have held to believe for sometime that any rise in bad debt is likely to like the economy and the deterioration in our self pay collection we saw in the quarter could be early evidence this.

Pricing gains were inline with expectations I wont repeat the stats, you can reproduce yourself in this morning’s filings. We had a very good cash story in the quarter. Adjusted free cash flow was a negative $135 million and improvement of $151 million relative to negative adjusted free cash flow of $286 million in the first quarter of 2008. As most of you know, we have large seasonal component of our cash usage in the first quarter, which amounted to $122 million this year for our matching 401K contribution and our annual incentive compensation payments

Our interest payments are also tilted to the first quarter and $149 million compared to schedule payment of approximately $65 million in the second quarter. On the subject to interest expense, we just completed a fixed variable interest rate swap with a notional amount of $1 billion against our 2013 debt maturity. This should produce instant interest savings of approximately $9 million in 2009 if there is stability in the one month LIBOR. We also put an interest rate cap in place to protect us against a precipitous rise in LIBOR above 8% over the term of the swap. After considering the swap including our cash position, we still have net floating rate exposure well below, well below the industry average.

You will also note the capital expenditures were only $101 million in the quarter, a level which we are comfortable given the financial retrenchment of much of our not-for-profit competition. This level of spending is also consistent with our CapEx outlook range of $400 to $450 million for the full year. Along with $251 million in proceeds from the sale of facilities, primarily USC and some favorable timing of $47 million in cash proceeds from Medicare HMO insurance subsidiary in Louisiana, which basically reverses the unfavorable timing on the same source of cash proceeds in the fourth quarter.

We ended the quarter $652 million in cash and cash equivalents. While on the subject to the Medicare HMO, I should note it’s disclosed at our 10-Q, this sale of that business, which had increasing risk to us and volatile results was completed on May 1.

Net income attributable to shareholders came in very strong at a $178 million or $0.37 per share. This was significantly aided by the $134 million pretax gain, $84 million after tax on our debt exchange.

This represents an item, which will gradually be reversed through earnings as original issue discount on the new bonds as amortized through the P&L. Net of this gain are a few other items detailed in our earnings release. EPS was $0.08 per share, well ahead of last year’s first quarter as well as the street consensus, which had us at about breakeven. As a result of this very strong start, we felt justified in raising our outlook for 2009 adjusted EBITDA by $25 million to a new range of $760 million to $825 million.

As I alluded to earlier, after reviewing our initial assumptions for the year in light of our actual performance to date for 2009. We remain comfortable with our outlook on volumes.

After leap year adjustment, total admissions for the first quarter declined by 0.1%. Just below our assumed range of flat to up 1%, but this was offset by stronger than assumed performance in commercial admissions, which came in with the decline of 2%, slightly ahead of our assumption of decline of 3%.

As we have already mentioned, we had a weaker than expected mix in April, which served to confirm our caution on the basis of a single strong quarter. This means we are reasonably consistent with our assumed revenue growth taking us to $9.0 billion to $9.2 billion in 2009 revenues.

Although we have good visibility into our near-term pricing there is some uncertainly with respect to IPPS rates for the fourth quarter. If the current proposal, which just came out as accepted, it would have an estimated negative impact on our assumptions going into the years of approximately $10 million.

We have reflected this change in our revised EBITDA walk forward. While we have already performed much better than our earlier assumptions is on controllable operating costs and bad debt.

Although there will always be some variability in costs performance with volume fluctuations, we believe the tools we developed to help our hospital operators flex their costs in response to daily movements in patient volume worked well in the quarter and gave us better costs efficiency than we’d assumed at the beginning of the year. Although we can’t quantify it, we also believe, we benefited from the effects of the economy on a labor base.

The bottom line of all this discussions as we are going to retain the conservatism we first established for year, in consideration that we are only a quarter the way through and there are still potential pressures from the economy on our payer mix and collectability of patient receivables. However, we’re remain confident in our strategies and believe they work to sustain paying volumes constrained bad debt and drive costs reduction in the first quarter at level better than what we anticipated and for that reason we are raising our outlook modestly for EBITDA for the year.

With that we will move to questions. Operator, please assemble the queue for our question and answer session.

Question-and-Answer Session

Operator

(Operator Instructions) Our first question comes from Ralph Giacobbe of Credit Suisse.

Ralph Giacobbe – Credit Suisse

Thanks, good morning.

Trevor Fetter

Hi, Ralph

Ralph Giacobbe – Credit Suisse

I just want to go back. Good morning. Just want to go back to just the comments around, slight deterioration of self-pay at the end of the quarter. Can you flush that out at all for us and then maybe just remind us what the, if you have given sort of the bad debt assumptions for the year and or maybe, where you think unemployment, sort of shakes out in your market based on your guidance.

Trevor Fetter

Okay well in terms of a collection rates we actually disclosed I believe the collection rates in their earnings release so you can see them there they, did move downward over the course of last year and then slightly more in the first quarter. The effects aren’t too dramatic on the quarter, but nonetheless they represent a trend, which we are watching carefully. Let’s see the second part of your question was..

Ralph Giacobbe – Credit Suisse

Just implied, and sort of implied maybe unemployment in the markets based on?

Trevor Fetter

Okay, on the unemployment rates, they very significantly market-by-market, some markets like Modesto, California had very high unemployment, others are lower than national average. However, having said that, we don’t see a strong correlation between unemployment and uninsured volumes or bad debt expenses. There are many markets were unemployment rising higher than national average, but we actually have increase in the commercial paying patients and paying patients and don’t have increases in uninsured and then there are other market, which operate more like what you would anticipate. So, unfortunately I know it would be nice to be able to model it you just can’t draw an absolute correlation.

Ralph Giacobbe – Credit Suisse

Okay and then, and sort of follow-up can you maybe talk about what you’re seeing in your markets. I think you mentioned during your prepared remarks a little about sort of the not-for-profit peers. Can you talk about your ability to maybe take share, just given maybe their struggles a little bit more and just their, dynamics around that, and at which point maybe we can more meaningfully potentially see it?

Trevor Fetter

Sure it's, it is very similar to what we said on the last call that not-for-profit it's hard to generalize some are doing well, but many of them are in distress and cutting their capital expenditures and it's a great time to be competing.

Ralph Giacobbe – Credit Suisse

And then If I could just squeeze in one more, just in terms of the outpatient trends obviously, little bit better than expected, somewhat counterintuitive, I guess just given the weak economy and expected pressure on elective or discretionary volume. Can you maybe just drill down a little bit what are your thoughts around the trends there, and maybe sustainability of those trends?

Trevor Fetter

Well, I think that we’ve been very pleased with our outpatients results over the last three quarters. Our outpatients surgery as you saw in the release was up 4.7% compared to the same quarter of last year. And that was divided between our hospital-based outpatients surgeries and our freestanding. Our hospital-based surgery really contributed a lot to that outpatient work, can I think all the efforts of our outpatient group to improve the access throughput, customer service, efficiency, of those facilities has made a big difference. Additionally on the imaging side, we’ve seen significant growth in imaging and we’ve opened several new freestanding imaging centers that have helped us to take market share in the relevant market. So, we are very pleased with our outpatient growth, we’re up scaling our focus in that area, resources and we think we can continue to grow that business and take market share.

Ralph Giacobbe – Credit Suisse

Okay great thank you.

Operator

Our next question comes from Adam Feinstein of Barclays Capital.

Adam Feinstein – Barclays Capital

Okay thank you good morning everyone. Just I guess a questions, a couple of questions here just Biggs, you had said a $10 million impact from the recent IPPS rule. I just wanted to see, if you could walk us through in terms of what your pricing assumption was previously, what your pricing assumptions well, I'm just trying back into what you’re assuming before for pricing for the fourth quarter on Medicare, and then additionally, my main question is just with the deflationary trend we have seen in terms of lower operating costs, throughout the sector, what are you guys thinking about managed care pricing going forward, do you think we will see a moderation in managed care pricing have you seen more push back from payers, I’m just curious to get your updated thoughts around managed care pricing? Thank you.

Biggs Porter

Okay, on the first question, actually would you restate it for me briefly?

Adam Feinstein – Barclays Capital

Sure. Yeah, you’ve made a comment before, if I heard…

Biggs Porter

It was $10 million IPPS rates, yes, thanks.

Adam Feinstein – Barclays Capital

Yeah

Biggs Porter

The, I think our prior assumptions were laid out in some detail in the 10-K so, I won’t go into all the granularity of it, but it was a low digit assumption. It was an, a substantially increase by any means, so that the $10 million in, only makes it fairly moderate change to what we originally assume going into the year. What we are looking at now, in that $10 million adjustment is about a negative 0.5% effective in the fourth quarter so, if you are looking at it from the standpoint of going from 2009 to 2010, it would be about a $6 million effect in the fourth quarter.

Adam Feinstein – Barclays Capital

Okay and in terms of managed care pricing, just are you guys anticipating moderation of managed care pricing just with the decline in the healthcare cost inflation and what you have seen recently.

Stephen Newman

Adam, this is Steve. We are pretty much totally contracted for all of 2009 in part probably half of 2010. We are certainly working with our managed care partners, and continuing to focus on getting paid appropriately for both our the acuity of our services, but what we are finding is more willingness on the part, of our managed care payers to do firm steerage to us, and to also pay us for performance where we have more upside for our hospitals hitting agreed upon clinical outcomes. So we are positive about the direction of our pricing with our managed care partners.

Adam Feinstein – Barclays Capital

Okay Thank you.

Operator

Our next question comes from Sheryl Skolnick of CRT Capital Group.

Sheryl Skolnick – CRT Capital Group

Thank you very much, and I don’t know that anybody said it and I don't usually, but nice job.

Stephen Newman

Thank you

Sheryl Skolnick – CRT Capital Group

Not that it was a surprise, also thank you for that. A couple of questions if I can, I have to go to the Medicare initiative, because I think probably the most interesting and unique thing that you all have said today, and something that’s been concerning me, sort of the starvation in the land of plenty notion, that has people like me, agent to Medicare you guys wont be able to afford to take care me. So I’m curious as to a couple items of that. I don’t want to steal your thunder from investor that a couple of items. First of all what has been the reception to those physicians and other parties with whom you've worked to roll this out. And that’s number one, two, and how are you going to roll that out, is it specific regions, hospital-by-hospital, but across regions. So, just give me a sense of that. And three, how quickly can you expect to see changes in the way people, think about treating patients, therefore in the whole process within the hospital to make sure that your profitable on every single Medicare patients enrolls and works out. And I have a follow-up?

Stephen Newman

Sure, we appreciate the questions and the focus on the Medicare profitability initiative, I’m not going to give a lot of details, because I want everyone to come to Investor Day, on June 2nd to hear our comprehensive presentation, but as a prelude, we’ve been impressed with the positive receptivity of our operators and staff in the hospitals as we’ve introduced them to the Medicare profitability initiative, we’ve rolled it out recently at our strategy conference for our company leaders. And they were very engaged and asked a number of questions and have really endorsed the process. We are involving our Regional Chief Medical Officers in the process, and there also very much on Board. The early indications and discussions with our doctors have also been very positive because they realize that they’re particular professional fees tearing from the managed care perspective potential changes and their access to Medicare funds with some of the initiatives in Washington, including the bundling of professional fees potentially to hospital based DRG payment are encouraging them to participate as active parts of redoing our cost structure. So, I think all in all we are very positive understanding there are some roads ahead of us in terms of changing the practice patterns and the delivery of care, but we are very positive of about it and certainly plan to give a lot of those details that you ask about on the Investor Day.

Sheryl Skolnick – CRT Capital Group

Okay, I don’t like getting sort of non-asked answer, but at least I got part of answer. So, let me turn to something then that’s a little bit maybe also non-answerable but nevertheless, crucial to the company. You have done a good job in terms of pushing out your near-term maturities, you’ve generated more cash in the first quarter than we thought you would had in large part due to the timing of the USC transaction, but also, just generating more cash from operations then you did a year ago certainly. And while, it’s great to push out maturities, it’s not great enough. You’re still highly levered company, when you’re going to start using some of that cash to reduce your debt. And what’s your thought process about that?

Biggs Porter

Well, certainly, if you go back six to nine months ago, when we first announced that we were in a transaction of USC. We answered that question by saying that our default assumption on the use of the any excess liquidity was to retire debt. Since, that point in time obviously a lot has changed and it does introduce the question of what is the excess liquidity in the current economic environment. And so, we have to certainly be careful on in any consideration of the use of the cash, this point in time. So, I don’t have a clear indication to give you is to what we will do, if we were doing - anything near-term, but certainly, are something we will monitor, over the long-term obviously the objective is to continue to produce additional cash, to our cash initiatives. Drive positive free cash flow so that we can delever through increasing strength on the balance sheet.

Sheryl Skolnick – CRT Capital Group

Okay, do you still have room on the balance sheet to generate as you said before cash from the assets that are there?

Biggs Porter

Yes, yeah the broad range of cash initiatives we talked about previously are still in place.

Sheryl Skolnick – CRT Capital Group

Okay

Biggs Porter

You didn’t ask me specifically about the MOBs, but I will talk about them since they are one.

Sheryl Skolnick – CRT Capital Group

Yes

Biggs Porter

Since there one of the biggest remaining pieces. We at this point are not under an active letter of intent on MOB’s, so we are going to have to consider whether we will start to sell them individually, or whether we will hold them for a longer then we had originally planned, and look dispose of them in 2010 or thereafter. Really, the market has improved, financing has become available, however it is expensive. And so it is not been helpful then to achieving full value for the MOB’s. And we’re not going to sell them on a fire sale basis. We don’t feel like we are in position, which would requires to do that. We have that liquidity otherwise as you just noted so, we’re going do what smart with respect to the MOB’s, but as of right now there is nothing active for 2009. I’ll go back to refresh you, we have taken the out of 2009 anyway previously, because of the uncertainty.

Sheryl Skolnick – CRT Capital Group

You have taken proceeds and assets from the sale of out 2009

Biggs Porter

Correct.

Sheryl Skolnick – CRT Capital Group

Cash balance, but the income from and it’s still in the EBITDA correct?

Stephen Newman

The income we had taken out of our outlook for 2009 however it’s not a big number.

Sheryl Skolnick – CRT Capital Group

Okay

Stephen Newman

So, it doesn’t change it much.

Sheryl Skolnick – CRT Capital Group

Okay and then if you will indulge me one final question, I think it’s important one. You are making great strides across organization, clearly management there must there must be better than people give the company credit for. I think I would like to have more understating of that, but deeper bench, but one of the key things that you can’t control is Washington, Trevor can you talk a little bit and your role as sort of chief lobbyist for the industry or leader of the pack there about what the key initiatives are that the federation intends to pursue given that now you are seeing IPPS and the coding creep adjustments and that conversation about, do you how much over, coding creep there is. I won’t mention the U word as well as some of the initiative that have been discussed in the Senate and the House.

Trevor Fetter

Sure thanks. Sure.

Sheryl Skolnick – CRT Capital Group

And include in that readmission if you would please.

Trevor Fetter

Okay, yeah I wouldn’t comment, a chief lobbyist for the industry far from it. While we have an excellent organization, I’m just Chairman of the federation for this year, but the member companies are very much aligned on the, big strategy of increasing access and coverage and I think it shouldn’t come as a surprise that as we pursue that and as the likelihood of increased access grows, government will look for ways to reduce their cost. And these tweaks that you see that are material tweaks are exactly that, they’re more technical in nature and the more fundamental debate is around access. These other concepts that are out there that tend to I guess be most frequently mentioned, whether it's through a Senate white paper or just in the press the things like bundling, readmission even the Dartmouth atlas and the disparities in spending from one market to another are all things that the, policy makers in government are looking at as ways to improve basically the value of what they’re buying in healthcare services. Turning coming back to Tenet for a second, we feel we are very well positioned for this because we’ve made all these investments in clinical quality, we’re a multi-hospital system so whether you throw a concept like bundling at us. We should be well prepared to access the risks of bundling, negotiate the contract that would be necessary to that so far. On readmission, there are many different definitions The term that’s being thrown around and nobody can exactly pin down exactly what anyone means by it. But as we have looked, taken a sneak peak at what our own readmission rates are in the most commonly accepted definitions, there are substantially lower than what’s being thrown around in Washington, as sort of the problem. So, I feel that and then finally on the clinical quality and value based purchasing types of initiatives, those are very similar to what we have sought with payers and we perform well in those payer – commercial payer based quality incentives. So, I feel like we are well positioned for those future costs that might come along as part of broader gain for this industry and greater access and coverage for the uninsured.

Sheryl Skolnick – CRT Capital Group

Will there be specific effort made to address the issue of coding creep given that, your Medicare initiative basically says, we don’t make money on Medicare to begin with and now you want to cut it some more?

Trevor Fetter

Yes, so, we’re specifically, Biggs gave an estimate as to…

Sheryl Skolnick – CRT Capital Group

Yeah

Trevor Fetter

What this would mean if it were enacted into law. The advisors that we have in Washington and industry groups, would say this is far from final.

Sheryl Skolnick – CRT Capital Group

Reason as…

Trevor Fetter

They are comment periods, it’s seems unreasonable, why now, I think particularly why when the industry is in distress? And, remember, that although the universe of companies that this audience follows tends to have EBITDA margin that exceed 10% on every company for this quarter that would represent, sort of a top 10% tile type of margins for the universe. This represents by the American Hospitals Association. So, as an industry it’s not perceived as an industry that is doing particularly well right now.

Sheryl Skolnick – CRT Capital Group

Excellent, thanks so much.

Trevor Fetter

Thank you.

Operator

Our next question comes from Shelley Gnall of Goldman Sachs.

Shelley Gnall – Goldman Sachs

Hi, great. Thank you. My questions are going to be around accruing for bad debts or doubtful accounts. So I guess my first question, when you see a fundamental change in your markets like unemployment rates rising 4%. Is that adequate basis for increasing accruals for doubtful accounts and is that fact that what you’ve done?

Biggs Porter

No we do not base our bad debt accrual any kind of macroeconomics indicator, instead we do based upon what our collection experience is. We look back in our 18 month period we also look at current experience in applying that standard. So it’s based more empirically on what we are experiencing as opposed to what’s going on in the outside. We think that keeps us fairly current. There is not a lag in terms of what we are reserving for but there maybe a lag ultimately in terms of how people behave going forward, what volume, what happened to the volume standpoint? Will uninsured volumes go up in the future because they are an arising unemployment they might, that would necessarily effect what we recorded for bad debt experienced today. That just decide the future risk and then future payments trends might vary but we wouldn’t go and project one once again into the future opposed to looking at what current experiences is…

Shelley Gnall – Goldman Sachs

Well, can you tell us what was your allowance for doubtful accounts in the quarter and also the allowance as a percent of self pay receivables?

Biggs Porter

Of the allowance is disclosed Well the allowance is disclosed at 10-Q I have to go back to find this number and so what’s your second part of your question?

Shelley Gnall – Goldman Sachs

You’re also indicated, you will give self pay, you’ll give the allowances as a percent of as percent of self pay I guess I can wait for that.

Biggs Porter

It's in the 10-Q and we’ve already filed it. So I’d refer you to the documents so you can get the right number and all the detail.

Shelley Gnall – Goldman Sachs

So, So it doesn't sound like we should be expecting a big uptick in either of those numbers as a percent of receivables?

Biggs Porter

No.

Shelley Gnall – Goldman Sachs

Okay

Biggs Porter

No and in fact, that the bad debt rate we’ve recorded in the first quarter was below what we recorded in the first quarter, I'm sorry actually, the fourth quarter of last year because uninsured revenues went down.

Shelley Gnall – Goldman Sachs

Great.

Biggs Porter

So collection rates have softened, but uninsured revenues have declined and that's a more important driver.

Shelley Gnall – Goldman Sachs

Got it. Okay then just a quick question on your correlation. Where are you seeing some markets that have the higher unemployment rates or actually seeing better commercial admissions? And can you just, and talk as a little bit about what you’re doing in those market on, talk a little bit about routing care. Is there better opportunity in your large urban markets to route care to County hospitals or Community Hospitals and also we’ve heard some of your peers in the not-for-profit industry at least talking about being able to pay a portion, the patients portion of COBRA, is that something that Tenet’s hospitals are able to do, which maybe offsetting some of these pressures.

Biggs Porter

Let me start Shelly talking about what we are doing in those markets in terms of a capturing more of the commercial managed care business, we’ve got a series of a tactics we’ve rolled out to the hospitals. They’re implementing including really expanded business-to-business initiatives, some work with payers in the area to create exclusive provider organizations. And just a whole host of things at the very local level, working on relationships. We’ve done somethings like, health fairs for school systems all focused on capturing a higher percentage of the available covered commercial lives in the relevant markets. So, I think we are continuing to upscale those and once again as the commercial covered live shrink across the country as the national payers have reported, we are after and focused on getting a bigger piece of the pie.

Shelley Gnall – Goldman Sachs

And an opportunity to pay the patients, portion of COBRA. Or you is that something that you’ve been looking with that?

Biggs Porter

We are certainly haven’t been do anything on those lines, and are looking to do it. The COBRA has been expanded, our coverage that’s been expanded, are subsidized through recent legislation, and we certainly think that, that has a positive influence but we can’t track that one either to determine, whether that’s having any kind of effect right now or not.

Shelley Gnall – Goldman Sachs

What about on Tenet, actual Tenet hospitals able to pay the patients portion of that COBRA is that an initiative that

Biggs Porter

No, that’s not an initiative, that we’ve considered at this point.

Shelley Gnall – Goldman Sachs

Okay, thank you.

Operator

Our next question comes from Darren Lehrich of Deutsche Bank.

Darren Lehrich – Deutsche Bank

Thanks, good morning, everyone. I just wanted to go back to the sustainability question regarding your costs trends and maybe ask in a slightly different way. Looking at controllable costs trends and growth in that trend is averaged about 2% for the last four quarters and about 3% over the last two years. So, I guess, I just wanted to revisit, in that context what’s the right level of growth in controllable costs over the next year based on what you are seeing today and remind us what, what’s in your guidance. Thanks,.

Stephen Newman

Yeah. On the, on a adjusted patient day basis, we had put the range at 2 to 3% previously, as we look to all of the metrics that we gave that outlook for 2009. that’s probably one were we’ve been most attempted to say maybe we’ll do better than that 2% to 3%. Although we didn’t specifically updated for purposes of this call, it may end up more in the range 1% to 2% for this year. It’s going to somewhat lost maybe in the rounding but certainly that’s an area where we had an opportunity to beat the outlook that we have published bank in at the fourth quarter call

Darren Lehrich – Deutsche Bank

Okay, that’s very helpful.

Stephen Newman

And that would be consistent with the fact we increased our cost initiatives by $30 million the savings from them as I mentioned in my script.

Darren Lehrich – Deutsche Bank

Right, okay and then my follow-up is just going back to the pricing question. I think someone asked before and I just wanted to follow-up in a couple of a other payers classes, how much of your Medicare advantage business in total Medicare business. Will you have the opportunity to reprice some of that business in 2010 and also can you just comment a little bit more on Medicaid pricing that you are seeing in both at the state level and Medicare regional? Thanks

Stephen Newman

As of it is the last part first on Medicaid generally, we presume zero change year-to-year on Medicaid pricing aggregate and that still be our assumption be it managed or otherwise and the relief that’s been given by the Government Of Additional State Funding this been made available through the stimulus bill as better step states capability or fun Medicaid. So, as a reminder, gone at the year worried about the funding at this point in time, we think the state should be sustain themselves and the Medicaid funding in that zero growth assumption is still a reasonable assumption. In terms of the classification between payers, just between the release in the 10-Q I believe the stats and the information is there so, I can take a minute to go dig out dig it up for..

Darren Lehrich – Deutsche Bank

No, I guess since because I am asking about that the mix will calculate that's from the Q to talk about pricing in you’re a MA business, as you look at 2010, what we’re in the subject to pricing, because doctor you would mentioned it, you’re seeing more pay for performance, opportunities our understanding is that that has been closure to about a 1% benefit if you can achieve that. Is that still consistent, is that the rate level of bonus that you’re receiving and do you think you can get more overtime.

Stephen Newman

Let me address the Medicare advantage and just sort of refer you to the 10-Q for the exact proportion, but about three quarters of our Medicare business is traditional and about quarter as Medicare advantage business and you can get those exact figures in the 10-Q, but with respect to pricing in the Medicare advantage contracts generally speaking they track pretty well with what happens to traditional Medicare. So, when MS-DRG payment goes up, you can expect us to get that sort of payment increased relatively from the commercial Medicare advantage plans. Recently, the government announced significant increase in orthopedic procedures for those particular, MS-DRGs. We anticipate that we will see those also in the Medicare advantage plans as we redo them for 2010.

Darren Lehrich – Deutsche Bank

Okay, great and then on the pay for performance structure ..

Stephen Newman

We are adding pay for performance to more commercial contracts, we started this about 18 to 20 months ago, and as we are renewing contracts with our existing managed care payers, more of them are willing to work with us on both the steerage through high performance networks as well as potential incremental payments for hitting the agreed upon clinical outcomes and so, we are pushing that pretty hard and you’re right it was probably about 1% but I think that particular amount at risk is probably growing at or slightly higher than our overall increases are in a percentage basis.

Darren Lehrich – Deutsche Bank

Great, thanks very much

Operator

Our next question comes from Whit Mayo of Robert Baird.

Whit Mayo – Robert Baird

Thanks, just wanted to follow up the question about the cost item and the sustainability of those trends I guess, just first maybe looking at medical malpractice in the quarter, I think, it was $21 million and you had $18 million in December and I think you mentioned that may not be somewhat sustainable going forward so have we bottomed down the large swings there and is sort of a $20 million numbers pretty reasonable I think about going forward, just how should we think about that?

Unidentified Company Representative

I think that, I tried to put it in my comments and granted it’s not a simplest of subjects, but the $20 million as a run rate we think it’s probably to low and not sustainable. Where I did comment on that was through remainder of the year. We still felt like we could be below last year. So, we can have a favorable trend for the rest of this year. So, I think that the fourth quarter adjustment implicitly there the under run and or decline in the fourth quarter. And then the decline in the first quarter represent larger decreases what we would think, would be expected to going forward, but we still expect to have good performance from this point. We put an awful lot into the call initiatives and otherwise controlling malpractice expense. We think those are paying off. We have very little in the way of large claims systematically overtime. So, we think we’ll continue to get the benefit from that even at the very low discount rate. So, we are going using the calculation today. So, we’re pretty comfortable continuing benefit, but that will be a quite a bit $20 million run rate.

Whit Mayo – Robert Baird

Okay that’s helpful. And maybe just thinking about the 401K match I think you froze that for all of 2009 and you paid I think 120, 123 this quarter. So I just want to sort of get a sense we have to think about that from a P&L perspective is that mean that in the first quarter of ’08. You would accrued about $30 million for the quarter, I just…

Unidentified Company Representative

The 120 was a combination of incentive compensation and 401K I think that the from a effective to 401K it’s in the neighborhood of $20 million for the full year. What the reduction amounts too from a cash benefit standpoint, that benefit won’t show up for the quarter until next year.

Whit Mayo – Robert Baird

Yeah, okay and then have you said any – are there any promises or any set dates which you have to readdress, reinstating some of these costs reduction I just want to get an ideas to when the thing maybe some of these reverse themselves if at all?

Unidentified Company Representative

No, we haven’t.

Whit Mayo – Robert Baird

Okay and maybe just one last final question, is just on the cost report settlements represents you factored some benefit in going forward. Can we get maybe a spot number to think about what you are contemplating for the remainder of the year just now there is no disagreement about this?

Unidentified Company Representative

No, we really, we really don’t project them. They obviously happen with some frequency, but it’s not build into our forecast on any kind of line item on a discreet basis.

Whit Mayo – Robert Baird

Okay, fair enough. Thanks guys.

Operator

Our next question comes from Gary Taylor of Citigroup

Gary Taylor – Citigroup

Hi, good morning. Just a couple detailed questions. And then one conceptual question. So, working through some of these costs numbers, which I will agree were quite impressive particularly coming in light of some reductions, you’d already put in place in ’08. You flushed out a few of these in that SW&B. Can we talk about a couple of others, for example the headcount reduction. Can you layout year-over-year FTE decline or dollar amount that came out of the headcount reduction?

Unidentified Company Representative

I don’t have the FTE numbers from a aggregate standpoint on; salary, wages and benefit you may recall from the first quarter call we said it was worth about $75 million of our cost reduction initiatives. However most of that was in benefited related areas. The risk component or reduction and force component of that was $120 million.

Gary Taylor – Citigroup

I’m sorry that the reduction in the workforce was $120 million.

Unidentified Company Representative

Correct.

Gary Taylor – Citigroup

And that’s a annualized number or that’s a

Unidentified Company Representative

That’s annual. That’s, well that’s the effect on the full year of the initiatives.

Gary Taylor – Citigroup

Got it. So, from a headcount basis, would the expectation be if volumes continue around these levels with not a lot of moment up or down that there would be additional FTE reductions or this is the place you will run?

Unidentified Company Representative

Garry let me just add that we had improved productivity. And improved average average hourly rates. And we’re continuing to drive on those everyday and every week, and respond tovolumes on a everyday network basis. So that you expect those to continue to focus on those areas as we move forward.

Gary Taylor – Citigroup

Okay the one other place in terms of overtime cost you gave us kind of the year-over-year contract labor changes, and were that’s running. Can you give us a sense of overtime like what that runs in a quarter and where that was year ago?

Biggs Porter

I don’t, we are going to have to dig that out.

Trevor Fetter

Yeah I don’t think we have the overtime statistic for you Gary.

Gary Taylor – Citigroup

Is that conceptually is that larger than the contract labor number or just?

Biggs Porter

It's a smaller number than the contract labor number.

Gary Taylor – Citigroup

Okay. And then my last question just for Trevor, you gave us the ’09 guidance just a couple of months ago, you raised it few weeks ago when you pre-announced, so just kind of conceptually, help us think about in the last couple of months, what’s turned out better? Thanks

Trevor Fetter

Okay, well going back to the opening comments that I made, what turned out better, volumes certainly were more stable than we had anticipated and I think given the economic environment certainly more stable than anyone have anticipated. We did relatively well on volumes in comparison to many of the peer companies that have reported and I think that's a result of the initiatives that we have had underway for a longtime building volume growth and recruiting and so forth as Steve mentioned. I think we also have exceeded the expectations that we set out as we put our plans together for the year in terms of cost reductions. So, the risk of restating what I said at the outset of the call the negative impacts on us from the economy have been milder than we had anticipated and our own ability to have basically everybody in the company embrace the challenge of driving cost reductions has exceeded our expectations. Meanwhile, the other variables like pricing have, remained relatively strong we also had been very concerned about bad debt, but we had also taken a series of very strong steps including investments in better capabilities and technology and also people right at the point of service in our hospitals in order to mitigate some of the pressures that we’ve seeing for years on bad debt. So we got, I think much more creative and much more effective in using technology to address bad debt. So if you kind of go though all those things, volume pricing cost, and in particular, a bad debt the ones where we expected negative pressure we had, we ended up doing better against the pressure than we might have anticipated and the ones they represented opportunities within our control like cost control, we did exceptionally well. And then with, it's important to mention cash flow and on the cash side both from operations and from the successful completion of the USC transaction, we did very well. And in addition we did that bond exchange, which although it was perceived by many as being defensive at the time, I think it was well timed, and it has made a material, positive impact, on the, risk profile of the company. So sitting here today, I think we’re pretty, confident about our ability to navigate through this difficult economic environment, and we have put the company in stronger shape than certainly it was at the end of December or even when we held the fourth quarter call, in which we expressed or outlook for the year.

Gary Taylor – Citigroup

Okay, thanks for running through that again.

Operator

Since we have no more questions. I would like to turn the call back over to Mr. Fetter for any closing remarks.

Trevor Fetter

Operator thank you, I have no closing remarks, except to remind people of our June 2 investor day. Thank you all for participating.

Operator

That does conclude today’s teleconference. Thank you for participating. You may now disconnect.

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Source: Tenet Healthcare Corporation. Q1 2009 Earnings Call Transcript
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