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Tenet Healthcare (NYSE:THC)

Q1 2012 Earnings Call

May 08, 2012 10:00 am ET

Executives

Thomas R. Rice - Senior Vice President of Investor Relations

Trevor Fetter - Chief Executive Officer, President, Interim Chief Financial Officer, Director and Member of Executive Committee

Daniel J. Cancelmi - Principal Accounting Officer, Senior Vice President and Controller

Britt T. Reynolds - President of Hospital Operations

Clint Hailey - Chief Managed Care Officer and Senior Vice President

Analysts

Ralph Giacobbe - Crédit Suisse AG, Research Division

Kevin M. Fischbeck - BofA Merrill Lynch, Research Division

Thomas Gallucci - Lazard Capital Markets LLC, Research Division

Adam T. Feinstein - Barclays Capital, Research Division

Sheryl R. Skolnick - CRT Capital Group LLC, Research Division

John W. Ransom - Raymond James & Associates, Inc., Research Division

Gary P. Taylor - Citigroup Inc, Research Division

Gary Lieberman - Wells Fargo Securities, LLC, Research Division

Whit Mayo - Robert W. Baird & Co. Incorporated, Research Division

Operator

Good day, ladies and gentlemen, and welcome to the First Quarter 2012 Tenet Healthcare Earnings Conference Call. My name is Jeff, and I'll be your coordinator for today. [Operator Instructions] As a reminder, this conference is being recorded for replay purposes. I would now like to turn the conference over to your host for today, Mr. Tom Rice, Senior Vice President, Investor Relations. And you have the floor, sir.

Thomas R. Rice

Thank you, Jeff. Good morning, everyone. First, I want to apologize for the delayed start. There was some confusion around the phone number. I believe we have that properly sorted out at this point, so we'll get started.

Tenet's management will be making forward-looking statements on this call. These statements are qualified by the cautionary note on forward-looking statements contained in our Annual Report on Form 10-K. [Operator Instructions] At this time, I will turn the call over to Trevor Fetter, Tenet's President and CEO.

Trevor Fetter

Great. Thank you, Tom, and good morning, everybody. Our performance in the first quarter got us off to a solid start for 2012. Here are some highlights. Adjusted admissions increased by a strong 2.8% against the tough comp of over 2%. That is stronger growth than all but one company in our peer group and it's also our sixth consecutive quarter of growth.

We achieved a 6.6% increase in surgeries, which is the best performance in our peer group this quarter. This growth came from both inpatient and outpatient surgeries. We grew ER visits by 5.2%, indicating that we're gaining share. We continued to realize commercial pricing increases in our targeted range of 5% to 7%. And as we demonstrated, once again, strong cost controls, including a 2.2% decline in supply cost per adjusted admission. Those are the operational highlights.

In addition, the Medicare rural floor settlement exceeded our expectations and provided us with $77 million of earnings in the quarter for a total EBITDA of $314 million. This result exceeded virtually all analysts' estimates and the consensus. The consensus was distorted by a wide range of estimates, some of which included settlements and some of which did not. The most accurate way to look at our performance in the quarter, however, is that it fell short of our expectations by $15 million.

Here's why. Our expectation for the quarter's EBITDA, excluding settlements and SSI, was $254 million. That would have been our point estimate in February when we said that Q1 would be roughly 1/5 of the full year. We came in x settlements and SSI at $239 million. Now while that was above the low end of the guidance that we gave you in February, it was $15 million short of our expectation at the middle of the range. The $15 million shortfall versus our guidance was created by 4 hospitals, each in a different region. The issues of the 4 hospitals are well defined and fixable, and Britt Reynolds and our regional and local management teams are already addressing the issues.

Turning to volumes. We're very pleased once again to report some of the strongest volume growth statistics in the sector. We grew adjusted admissions by 2.8% due to strong performance on the outpatient side of the business, where about 75% of the growth was organic. That's much stronger organic growth than in recent quarters. Surgeries grew by 6.6%, driven by strength in both inpatient and outpatient. We're very pleased with the organic growth of our existing outpatient surgery business and the strategic decision to augment that growth through acquisitions.

Volumes in our emergency departments remained strong, growing by more than 5%, fairly evenly across all payer classes. This provides compelling evidence that our historical investments in ER facilities, technology, throughput and service are helping us gain market share.

As you've heard on other conference calls, it was a very light flu season. Normalizing even to last year's light flu season would have added 30 basis points to admissions growth. Acuity was slightly softer in the quarter with our Case Mix index declining by less than 1% to 1.33. Commercial CMI had a slightly better trend than our aggregate acuity. It's interesting to note that the largest declines in acuity were among our uninsured and charity patients.

Turning to service lines. We saw a significant strength in orthopedic and spinal surgery, major trauma and G.I. disorders relative to the first quarter of 2011. These service lines were all targeted as part of our targeted growth initiative. We've been working on building these service lines for years, and it's extremely gratifying to see this growth. Steve Newman, who is with us here today, will have retired prior to our second quarter call, so I'd like to recognize him for the targeted growth initiative. It's something that he piloted in California some years ago and it, along with our other strategic initiatives, are major drivers of the improved performance that we've generated. These initiatives drove our 15% compound annual growth rate in EBITDA since 2004.

Returning to a review of the quarter. We continue to meet our pricing objectives, which include an increase in net inpatient revenue per patient day of 2.1% and a 5.5% increase in commercial inpatient revenues per patient day. On the outpatient side, net revenue per visit increased by 2.3% and commercial revenues per outpatient visit increased by 7.1%. We also continue to have excellent visibility into our future commercial pricing. We've completed contract negotiations for approximately 95% of 2012 and 40% of our 2013 expected commercial revenues. Selected operating expenses were well controlled, increasing by just 1.9% for adjusted admission.

Our Medicare Performance Initiative or MPI continues to drive incremental cost savings. One of the areas where these MPI savings are particularly visible is in our supplies expense line item, which declined by 2.2% per adjusted admission. Our bad debt ratio was 7.6%, a sequential quarter decline of 10 basis points. Our overall collection rates are essentially flat year-over-year and sequentially.

In terms of cash, we typically have significant outlays in the first quarter due to the timing of our compensation and benefit expenses, including 401(k) and annual incentive payments. Net cash usage by operating activities in the first quarter of 2012 was $42 million compared with $2 million in the first quarter of 2011, an increased cash usage of $40 million.

Last year, we had cash proceeds from the California Provider Fee program that were $43 million greater than the proceeds this year. So normalizing for this timing difference, cash from operations was basically flat year-over-year. We invested $136 million in capital expenditures in our businesses in the first quarter, and we used $26 million to repurchase 5.3 million shares of common stock. This purchase completed the $400 million program that we announced a year ago. In the aggregate, this program retired 81 million shares or 17% of our prior share count at an average price of $4.94 per share.

As you know, we repurchased roughly 90% of our mandatory convertible preferred stock at the end of April. This removed an overhang of up to 51 million incremental common shares. Without the repurchase, we would have had to issue those shares in October. I'm very pleased that following this transaction, both S&P and Moody's reaffirmed and Fitch upgraded their ratings on Tenet's debt. The stock buyback and repurchase of the preferred speak to our confidence in the future financial performance and value of the company. We saw a compelling opportunity to enhance shareholder returns, and we took prompt and aggressive action. Eliminating these shares brings our total reduction in share count to almost 25% of the fully diluted share count from a year ago. We have now 411 million shares outstanding and 434 million shares on a fully diluted basis.

As you saw in our pre-release and as we reconfirmed from this morning, we raised our 2012 outlook for adjusted EBITDA by $25 million to a new range of $1,250,000,000 to $1,375,000,000. We expect the quarterly pattern of earnings in 2012 to be weighted toward the second half of the year, which is largely the result of California Provider Fees and Health IT incentive payments that we expect to recognize in the fourth quarter.

Additional items which will contribute to the growth of earnings in the second half of 2012 include the closing and integration of incremental outpatient acquisitions, additional cost efficiencies from the Medicare Performance Initiative and enhanced patient volumes from the new physicians we've added and our adding to our medical staff. A big contribution should also come from getting the 4 hospitals, which were below budget in Q1, back on track. As we stated in the pre-release, our second quarter outlook for adjusted EBITDA is expected to be in a range of $225 million to $250 million.

To briefly summarize, we achieved stable inpatient volumes and impressive growth in outpatient volumes in the quarter, performing very well in comparison to our peer group. I'm extremely pleased with our growth in surgeries and ED volumes, and I'm greatly encouraged by the growth that we achieved in our targeted service lines. Commercial pricing trends continue to be favorable. Costs remain well controlled. And while bad debt expense remains elevated as you would expect in a soft economic environment, it remains stable and within our anticipated range.

While I've mentioned several drivers of our margin growth, I haven't mentioned how we're tracking on our Health IT, Conifer or our outpatient acquisition strategies. Our Health IT initiative is proceeding on time and on budget. In addition to the 7 implementations that we completed last year, we completed 7 more just in the first quarter. Conifer continued to meet its performance milestones, and we remain pleased with the strong pipeline we've identified in outpatient acquisition opportunities.

So that's it for my prepared remarks. I'm joined here by Britt Reynolds, our President of Hospital Operations; Dan Cancelmi, our Chief Accounting Officer; and other colleagues who are ready to answer your questions.

So operator, please begin the Q&A portion of the call.

Question-and-Answer Session

Operator

[Operator Instructions] Our first question comes from the line of Ralph Giacobbe with Crédit Suisse.

Ralph Giacobbe - Crédit Suisse AG, Research Division

I guess when we start thinking about the second half of the year, aside from the California Provider Fee and HITECH payments, any other things we need to consider that would help because the implied ramp in the underlying business seems pretty steep? So maybe any specifics there you can give and then maybe along those lines talk about what you can do for those 4 hospitals that you had discussed earlier that caused some of the shortfall in the quarter.

Trevor Fetter

Sure thing, Ralph. I will – I'm going to draw on a couple of comments from some of my colleagues, Dan Cancelmi as well as Britt Reynolds on the second part of your question. So there are a number of things that are weighted toward the second half. They're very helpful. You called out the California Provider Fee, some Health IT fees. It's really a timing difference that's occurred in the recognition of Health IT. But all of these things are payments that are essentially in lieu of either what have historically been higher Medicaid rates or incentives that would have been recognized in earlier periods. So although it creates this ramp toward the second half of 2012, really, those payments ought to be sort of recognized into earnings over earlier periods, just you can't do that under GAAP. In addition, we've got initiatives that have created this momentum that we've been showing in volumes that are intended to get stronger as the course of the year unfolds. There are other minor items, including some provider fees in other states that should be kicking in, in the second half of the year. We've anticipated a lot of this into the fourth quarter. And so, Dan, did I leave anything out that is worthy of mention that's part of that ramp-up?

Daniel J. Cancelmi

I think also looking at our MPI initiatives, we think there's further opportunities there in the second half of the year, not only on the salary wages line but also on the supply expense line item as well. And also, there's some additional pricing opportunities in the second half of the year as well as we're looking at, hopefully, get some bad debt improvement also in the second half of the year.

Ralph Giacobbe - Crédit Suisse AG, Research Division

And I guess just to follow -- I'm sorry, do you have more?

Trevor Fetter

Well, I was just going to add then there's this other very material thing which is getting the 4 hospitals I mentioned back on track. So I hope not steal the thunder of anybody else who want to ask that question, but Britt, why don't you just comment a little bit on what you've seen in those hospitals and how achievable it is to get them back on track?

Britt T. Reynolds

Sure. As Dan alluded to, the opportunities that exist in those hospitals to get back where we are accustomed to seeing them perform and where we would project them performing in the balance of the year is really in those areas that Dan alluded to, the TGI initiatives. There's some variation in those hospitals among our others where we could see a return back to performance and those targeted growth initiatives. There are some bad debt opportunities in some. There are expense initiatives such as salary, wages and benefit opportunities, as well as some payor mix and mild acuity issues that Dan had alluded to. There are not any one particular issue that is systemic across the 4. As Trevor alluded to earlier, they are in 4 different regions, so there's nothing with a particular state's payor or anything that would cause us concern from a systemic standpoint. It's more of a focus on those particular 4. I can tell you that we've dedicated each of our regional leadership teams in those regions to those hospitals. The reports I'm getting back are improving. The data that I see and the discussions I have with those regional leaders and the hospital leaders are that, while we don't give intra-quarter guidance, I'm very encouraged by the improvement seen on volumes and on some of these initiatives that I spoke about were some of the challenges. We saw that in April and just a week into the current month, we see that continuing to move along the lines we'd like to see. I think, going forward, as you asked the question about the outlook, I feel confident that we have the right team in place and the right things under focus to get those where we need them by the end of the year.

Operator

Our next question comes from the line of Kevin Fischbeck with Bank of America Merrill Lynch.

Kevin M. Fischbeck - BofA Merrill Lynch, Research Division

Could you talk a little bit more about the pricing? I guess it was worse than what you're looking for. I guess sounds like mix shift was the big issue there. Could you talk a little bit about what happened there, what was driving that? And it sound like one of the things that you were talking about as far as potentially improving the 4 assets was trying to help the payer mix. So is there anything that you're doing there to try and actively manage that or is that just a function of the economy?

Trevor Fetter

Yes. So there was some effect across the portfolio, and I think others in the industry have talked about this as well. Slightly lower acuity was driven more by shifts in service mix than anything else. And we listened last week to the earnings call of HCA. I think our acuity moved identically to theirs. So nothing unusual, but I think that some of those pricing stats were driven by those changes, which were really pretty minor.

Kevin M. Fischbeck - BofA Merrill Lynch, Research Division

But you mentioned that you had surgery volume across inpatient and outpatient. Can you break out the surgery growth between those 2 things? And I guess, is it that your target growth initiatives are geared towards some of these lower acuity items or...

Trevor Fetter

No, no. Actually to the contrary. The targeted growth initiatives are geared to things like the orthopedic and spinal surgeries where they were 2 of our strongest performing service lines. I think a couple of key points on the surgery statistics. One was that the growth came from both inpatient and outpatient. So that's important to see that growth returning in inpatient, was something we were very pleased to see. And the second important point was that of the total growth in surgeries, 75% of it was organic. We've had some quarters going back over the past, say, 4, where the percentage of growth in surgeries that was being driven by acquisitions of surgery centers was higher than that. So we're really pleased to see the organic growth as strong as it was.

Kevin M. Fischbeck - BofA Merrill Lynch, Research Division

So is it really just the OB volume? I guess what grew very quickly that kind of outweighed the progress you're making on [indiscernible].

Trevor Fetter

Yes, OB grew pretty quickly.

Kevin M. Fischbeck - BofA Merrill Lynch, Research Division

That's the main one?

Trevor Fetter

And that also affected length of stay.

Operator

Our next question comes from the line of Tom Gallucci with Lazard Capital Markets.

Thomas Gallucci - Lazard Capital Markets LLC, Research Division

I guess on the managed care front, I think you'd mentioned that rates were locked in for various percentages this year and next. Can you give a little bit more color on rates? And then I think that with the preannouncement, you might have talked about possible loss of a managed care contract. Just wondering if you had any update there and maybe any general commentary on sort of how contentious negotiations are maybe now versus a year or 2 ago.

Trevor Fetter

Okay. Tom, it's a good question, and I'm going to ask Clint Hailey, our Chief Managed Care Officer, to talk about both the disclosure we made in the pre-release, specifically, also just trends generally in pricing. I would point out, as I turn it over to Clint, that we did disclose these commercial pricing statistics of inpatient up 5.5% and outpatient up more than 7% to add some proof to our assertion that we're still getting rates -- or showing rates of growth in commercial pricing that are consistent with the expectations we've set. But Clint, why don't you talk about the issues that Tom has raised?

Clint Hailey

Sure. Let me start by saying that pricing is on plan. We've given some guidance on that, and we're achieving that guidance. We do have good visibility into our pricing for next year, as Trevor mentioned in his earlier comments. 95% of our revenue, commercial revenue, is locked in for 2012 and about 40% for 2013. As it relates to the one health plan that we talked about in our pre-release, that health plan, in the interest of respecting where we are in the negotiations, should remain nameless for now. But I do think it's important to point out that they're not amongst our top 15 commercial payors, and so the impact is somewhat muted as a result. Nevertheless, we do -- we are taking actions to address that, so that we can accomplish our aims.

Thomas Gallucci - Lazard Capital Markets LLC, Research Division

And the rates that you're seeing, I know you got a lot locked in, but what sort of rates are we looking at?

Clint Hailey

Well, we've given guidance on 5% to 7% range, and as Trevor mentioned in his comments, our inpatient revenue per patient day on the commercial book was 5.5% in Q1 and our outpatient per visit was 7.1% in Q1. So very much within that 5% to 7% range.

Thomas Gallucci - Lazard Capital Markets LLC, Research Division

Right. And that's what you're getting as you look out to '13, for example?

Clint Hailey

It varies by health plan. I mean, some cases were higher, some cases were lower. But we feel very confident that the 5% to 7% range is appropriate.

Operator

Our next question comes from the line of Adam Feinstein with Barclays.

Adam T. Feinstein - Barclays Capital, Research Division

Just, I guess, Trevor, maybe just to go back through something here. So it seems like -- I mean, volume growth was strong and you talked about the $15 million relative to how you were thinking about it on the EBITDA line. And you talked about the mix and the impact from that, but maybe just to talk a little bit more about the cost. And you mentioned the supply cost being down about 2%, but maybe just talk about some of the other cost line items as well, and I guess just trying to think about how the costs came in relative to how you were thinking about it. And I guess, is the mix really the main issue here? Is that a fair way to think about it?

Trevor Fetter

I think that it's -- I mean, just cutting right to the bottom line, I think that is a good way to think about it. You could explain it that way or you could explain it by looking at 4 hospitals because we had 4 who were so far off budget, that's really the way we're looking at it. It's not a macro trend, but it's something much more isolated to the 4. Cost control, I will ask Dan and Britt to comment on that, but I mean pretty much all the costs that are within our control we are controlling very effectively. Now there are some costs that we are incurring as a way of investing in our future. And so HIT, that large initiative, because of the change in the accounting recognition of the HIT incentives went from a profit center to a cost center this year. But it's still something that's very important to do. Same thing goes for the investment in continuing to employ physicians. It's an offensive and a defensive strategy. So I didn't really talk about those costs too much, but embedded within our overall costs are investments that we are making in the form of expenses in both the HIT and the physician area. As for cost control, generally, Dan Cancelmi is our -- there's nobody better in the company at controlling costs than Dan, so you want to talk about some of the other line items?

Daniel J. Cancelmi

Yes, Adam, our costs came in below our expectations for the quarter, so we were quite pleased. And as Trevor mentioned in his opening remarks, our supply costs were actually below last year's first quarter. And I know if someone looks at our earnings statement and looks at the other operating expense line, there is an increase in those costs, but those were planned, expected, some of them related to some items from last year. They were unusual items where we had some credits related to some refund items, we sold a medical office building. So we were quite pleased with our overall cost performance in the quarter. And again, we were -- our costs came in below our expectations.

Adam T. Feinstein - Barclays Capital, Research Division

Okay. And just -- so one follow-up question. And just so costs came in lower than what you were anticipating and you mentioned before about some of the things like HIT costs and the physician costs embedded in there. So I guess, just as you're thinking about the rest of the year and just, because once again, volume growth looked pretty good, so it just seems like this is a function of managing mix and you're managing the costs. So is it your expectation that you'll see a gradual improvement in the mix? Or -- and I know it's hard to think about it, but just trying to better understand the impact from that.

Trevor Fetter

Well, mix is always the hardest possible thing to control. But as Britt mentioned, we've seen already some encouraging trends just in the last 5, 6 weeks.

Operator

Our next question comes from the line of Sheryl Skolnick with CRT Capital.

Sheryl R. Skolnick - CRT Capital Group LLC, Research Division

And as usual, there's a whole bunch of questions. So first, I think I heard you say that this was Steve's last call. Britt, so now the focus shifts to you, which I hope that you're looking forward to. I guess I want to drill down a little bit more on these 4 hospitals, if I may, and also just clear up a detail point. And the detail point is when Health Net reported poor earnings the other day, your stock seemed to go down in sympathy, so as part of the operations or your answer, I would welcome a clarification on your exposure to Health Net and whatever pricing pressure they might bring. But I'm curious about these 4 hospitals, Britt. Now that you've been in the role for 4 months, are you satisfied that as these hospitals were underperforming, you had sufficient information to know that they were underperforming and, perhaps, to take some preventive action? And are the issues at these hospitals things that are as a result of the competitive positioning of the hospital, the operations of the hospital or are there things that you would like to change? Or is it simply that for – is there some other reason. But a little bit more detail on these 4 hospitals I think would be instructive so that we could get a feel for just how much effort there will be to bring them around by the end of the year. And I have a follow-up.

Britt T. Reynolds

Sure, Sheryl. The 4 hospitals are definitely in competitive marketplaces. So as we continue to work our MPI and TGI initiatives that you're familiar with in those marketplaces, we're obviously competing, and so that is going to be a function. As we've alluded to some of the challenges that we've seen on the payor side would apply to these, and as Trevor mentioned, that's a little bit hard to predict on a go-forward basis or in a proactive basis daily. But in terms of the expense management, I believe there is significant opportunity in that. I don't think these hospitals performed as well as they could from an expense standpoint. And a part of that is something that we identified and addressed but can't be turned over night. But I don't think these are things that are outside of our control to get our arms around and make significant improvement in throughout the course, even intra-quarter, as I alluded to. And I am encouraged intra-quarter at these 4 hospitals. Part of it's volume at those hospitals as well, just pure volume. And that to me is probably the most encouraging sign I've seen.

Sheryl R. Skolnick - CRT Capital Group LLC, Research Division

And the volume is rebounding?

Britt T. Reynolds

Yes. Yes, Sheryl, it is, and particularly in those 4. And overall, it's strong.

Sheryl R. Skolnick - CRT Capital Group LLC, Research Division

Great. Which will lead into my next question, which is so you've got – at the other, I guess it's 46 hospitals, you clearly had good results if not strong results. They're not translating into cash flow, so how should we think about the translation of the performance of the hospitals into cash flow for this year? And at what point do you think the company will be generating measurable free cash flow?

Trevor Fetter

I'll ask Dan to go ahead and take that question.

Daniel J. Cancelmi

In terms of our cash flow, first quarter is usually a usage of cash historically for a number of reasons, timing of year-end payables and some of our incentive compensation plans and our 401(k) funding for our employees. So actually, our cash flow in the first quarter also was a little bit lighter than -- in terms of the usage, it was lighter than what our expectations were. The primary difference if you're looking year-over-year is essentially just due to the timing of the cash flows coming from the California Provider Fee program. First quarter last year, we received approximately $50 million. In the first quarter this year, it was around $10 million, so there's about a $40 million delta between the 2 time periods. In terms of your question on, in terms of looking out into the future, you'll probably see cash usage in the second quarter. And then as we go through the third and fourth quarter, and consistent with prior years, we'll start generating cash from operations, free cash flow.

Sheryl R. Skolnick - CRT Capital Group LLC, Research Division

Okay. Just a follow-up on that, and I didn't get an answer on Health Net, the usage in the second quarter is not what you showed last year, so can you comment on that difference?

Trevor Fetter

You sort of faded out on us there, Sheryl.

Sheryl R. Skolnick - CRT Capital Group LLC, Research Division

I said the usage in the second quarter is different from -- a different path from last year, and so can you comment on that difference, and also I didn't get an answer on Health Net.

Trevor Fetter

Yes, we'll circle back to -- actually why don't we do Health Net now. We'll circle back to the cash question. So yes, I was surprised by the way, somehow being guilty by association for having operations in the same state as Health Net. We didn't really follow the Health Net situation very much, but I think it is toward the bottom of our top 15 payors. We don't have very much exposure at all. It's limited to a couple of markets of ours in California.

Daniel J. Cancelmi

I'm getting back to the cash flow question in second quarter, Sheryl. We'll have some debt maturities that we'll have to retire in the second quarter as well as some settlement payment related to the recent government settlement.

Operator

[Operator Instructions] Up next, we have John Ransom with Raymond James.

John W. Ransom - Raymond James & Associates, Inc., Research Division

I know we've kind of talked around this, but we calculated your EBITDA down quarter-over-quarter about 15%, if you strip out the onetimers from both quarters. Is it possible -- could you break down that 15% among mix, bad debt and maybe higher year-over-year HIT costs and anything else I didn't think of?

Trevor Fetter

First, can I take issue with the onetime characterization? Look, if you're going to strip out supplemental Medicaid revenues, you might as well just -- there's no end to what you should strip out. It doesn't make any sense. Used to be that we just got paid rates for Medicaid that were payments for what we did. And now in state across the country, I think there are 35 out of 50 states that now have these programs, you get paid a lower rate. And then for having some characteristics, it could be -- used to be disproportionate share. Now it's a share of heads or sometimes it's a share of dollars or whatever, you're getting these supplemental payments. And they tend to occur at unique points in time and some have large retroactive elements to them. The same thing is true with the Health IT incentive payments, you're incurring costs and expending effort along the way in a very even manner and then you receive these payments when you reach certain milestones. So I really -- John, we need to kind of change the dialogue away from characterizing some of these items as onetime because they're really not.

John W. Ransom - Raymond James & Associates, Inc., Research Division

Well, I guess I was thinking of the large -- I mean the California Provider Fee last year, 1Q '11, was pretty large, and I know it shifted from 4Q to 1Q and then this year you got $77 million from the Medicare settlement. I guess those were the 2 things that I was thinking were not going to recur each of this quarter.

Trevor Fetter

Yes, but not to be argumentative, but the California Provider Fee, we're going to get a very large payment in the fourth quarter of this year. And that is essentially to compensate us for Medicaid revenues we've not been receiving in California all along in this period. And you're going to continue to have those kinds of payments. Now the $77 million is really interesting because there was this sort of companion piece of an SSI hit, which for us was incredibly mild. It was $2 million. For others, it was much larger, but let's look at those 2 items, which you're characterizing as onetime. On the SSI piece, that was based on rates that were issued in 2009. And beginning at that time, we started accruing expense or accruing lower revenues, in essence, taking a hit for that in 2009 and '10 and '11. By the time we got to 2012 and these rates were issued just a few weeks ago, that's why our hit on SSI was so low. So our earnings have been depressed by virtue of accrual for those SSI rates all along. At the same time, the entire industry knew that the government had underpaid us on Medicare rates on this rural floor calculation for a very long time, and you're not allowed to accrue for an expected positive settlement. So all of a sudden it came, but what it really was doing is just adjusting for payments that should have been received over a longer period. And where it really appropriate to do so, we could publish pro forma statements that would show how the company would have performed had those payments been received in the time period now that they were attributable to. But it's just not the way you can actually do it.

John W. Ransom - Raymond James & Associates, Inc., Research Division

Well, and I didn't mean to cause this big debate. I mean, it's just hard. Given all this, it's hard for people with SEC educations like myself to try to determine what's going on when you try to normalize. And I was just asking for some help trying to normalize because I also realize you're incurring costs this quarter with HITECH that probably are higher than what you had normally incur, and the bad debt increase was a little surprising just given where we -- presumably, the economy is getting better, so that was a little bit of a surprise. So we're just trying to figure out...

Trevor Fetter

I understand, and I don't mean to be argumentative, so Dan Cancelmi, who's actually much nicer than I am, would like to help answer your question.

Daniel J. Cancelmi

Just to address the HIT. The incremental costs over last year, roughly $5 million. And the other thing to keep in mind is first quarter last year, again, one of these timing issues, we recognized about $25 million of HIT incentives in the first quarter last year and there was only about $1 million this year. Again, just due to timing of when those items can be recognized.

Operator

Our next question comes from the line of Gary Taylor with Citigroup.

Gary P. Taylor - Citigroup Inc, Research Division

I guess, if we just look at the EBITDA as reported, it'd be $379 million down to $314 million. And I'm sure kind of the core underlying operating trend is better than that. So I guess that...

Trevor Fetter

It is.

Gary P. Taylor - Citigroup Inc, Research Division

In concept of wanting to try to normalize the period.

Trevor Fetter

Yes, and that's part of the challenge in trying to do something on a sort of pro forma where you spread out because then you would have spread that $379 million out over prior periods as well.

Gary P. Taylor - Citigroup Inc, Research Division

A couple questions. I just wanted to make sure on the same-store statistics or the organic statistics that I'm just have some of the stats right. So on Page 7 where you show the net inpatient, net outpatient revenue, it appears those numbers exclude the Medicare settlement and since HIT got reclassed out of revenue last year, I presume the first quarter '11 excludes that and it doesn't look like the California Provider stuff from last year -- is that all correct, that those types of items are excluded from the revenue disclosure on that Page 7 table?

Trevor Fetter

Dan's got it in front of him. Go ahead, Dan.

Daniel J. Cancelmi

The rural floor settlement will be included in the numbers. You're correct about the HIT incentives from last year, they are not in the revenue.

Gary P. Taylor - Citigroup Inc, Research Division

Okay. So the rural floor is in there and then also then the California and Pennsylvania tax from a year ago is probably still in that first quarter year ago figure?

Daniel J. Cancelmi

The Provider Fee revenue, yes.

Gary P. Taylor - Citigroup Inc, Research Division

And then so if we're kind of looking at it, and also these figures would include, I guess -- would this include some of the outpatient acquisitions and ASC acquisition, so it's not purely a same-store figure?

Daniel J. Cancelmi

It does include our outpatient businesses, the centers that we do pick up.

Gary P. Taylor - Citigroup Inc, Research Division

Got it.

Trevor Fetter

In order to be same hospital, they've got to be within the hospital's market area or under its license. So there's a definition where it is actually a part of the hospital.

Gary P. Taylor - Citigroup Inc, Research Division

Fair enough. And then so, I guess, this is where I'm kind of getting at just trying to think of the quarter. So I guess it looks like kind of same hospital net revenue of 1.5% off of that table, adjusted admissions up 2.8% and I think even in the Q confirms kind of the calc that net revenue per adjusted admission down about 1.3%. And so I guess with pricing up, acuity only down a little, I guess a few guys have kind of commented on mix, but with surgeries up, I'm just trying to reconcile kind of that down 1.3% and I guess the surgical mix was either a lower acuity mix or just different payor class than ideally what you'd expect or what you had a year ago. Is that the right way to think about it?

Daniel J. Cancelmi

Yes, so let me address the decline in net revenue per adjusted admission of 1.3%. The big driver there is actually the growth in our outpatient volume. As you know, our outpatient business has a lower revenue per unit metric. The per visit number's a lot lower than our per admission number. And as that outpatient business grows, it will drive down your adjusted revenue per admission. And so, actually that accounts for about 270 basis points of that decline. So the 1.3% actually is positive 1.4% if you put our outpatient business on the same level as it was last year. So they did – it's a pretty dramatic swing.

Gary P. Taylor - Citigroup Inc, Research Division

And then there should also have a deflationary impact on expense growth per adjusted admission, I guess, as well which was higher than that this quarter. Because you're basically saying outpatient revenue is inflating the adjusted revenue or the adjusted admissions debt and then dividing your net revenue by that is driving a lower sort of perceived pricing stat, right?

Daniel J. Cancelmi

If you look -- that's correct. If you look at the ratio of adjusted admissions to admissions, it's about 1.55, I believe, this year and it was about 1.50 last year. So if you normalize, if you assumed our outpatient business was consistent with last year, that metric would have been an increase of 1.4% instead of the negative 1.3%.

Gary P. Taylor - Citigroup Inc, Research Division

That's helpful. My last question, if you'll indulge me. Just going back to the commercial contract back from the pre-release where you talked about the possibility. I think someone else mentioned in this call, but I'm not sure I heard the answer, perhaps I wasn't listening carefully enough. But can you talk about kind of, is that purely a rate growth dispute? Is it likely to be resolved? Is it related to anything else in terms of risk assumption or what are we to think about that contract?

Trevor Fetter

Clint, go ahead.

Clint Hailey

Sure. Yes, we did not name the health plan in question just in the spirit of where we are in the negotiations. We didn't feel it appropriate to call them out. And as it relates to the causes of the issue, it has to do frankly with expectations. The industry at large has certain expectations about what renegotiations look like right now, as do hospitals. And typically when you see a dispute between a health plan and a hospital, somebody stepped out of line relative to those expectations. Our expectations are driven by on a rate parity strategy that we've had for many years with regards to trying to keep all the health plans within a relatively narrow range of one another from a pricing standpoint. And this one is more difficult, if you will, as it relates to those ranges.

Trevor Fetter

I mean just to be clear, Gary. This is a decision we didn't take lightly. You haven't seen this from us, I don't think almost at all in the last 5 or 6 years. So we made a decision to initiate termination of the contract obviously because we feel it's in the best long-term interest of our business even if it creates the potential for short-term disruption. Pretty much as simple as that.

Operator

Our next question comes from the line of Gary Lieberman with Wells Fargo Securities.

Gary Lieberman - Wells Fargo Securities, LLC, Research Division

Have you guys had a chance to look at what the impact would be from the proposed changes to the allocation of Texas Dish [ph]?

Trevor Fetter

Dan, if you had a chance to look at that, I have not.

Daniel J. Cancelmi

We've done a preliminary assessment. We don't believe it will have a material impact on our numbers.

Operator

Our next question comes from line of Whit Mayo with Robert W. Baird & Company.

Whit Mayo - Robert W. Baird & Co. Incorporated, Research Division

Sorry if I missed this and you usually have a really good slide deck with this information, but did you confirm your 2013 to 2015 outlook?

Trevor Fetter

Well, I think we've seen no reason to change it. I don't know that we have to actually affirmatively confirm it every time, but consider it confirmed by virtue of the conference call.

Whit Mayo - Robert W. Baird & Co. Incorporated, Research Division

No, that's fair. Sorry, just had to ask. And looking at -- Trevor, looking into your Q at your physician income guarantee disclosures, the total liability now is about $146 million. I know the estimated liability, the real liability is lower than that, around $100 million or so, but that number has doubled in a year and maybe if you could just talk about the strategy there and what the corresponding P&L cost is now. I guess I'm trying to put that number into perspective since it's growing so much, which presumably is a good thing too.

Trevor Fetter

Yes. I mean, it's part of our strategy. We've talked about it for a couple of years about physician alignment. And when you hire or relocate physicians, you end up with these multi-year contracts. It's just this kind of standard way of doing it in the industry. And so, Dan, do you have any comment on the disclosure or...

Daniel J. Cancelmi

That's exactly right, Trevor. It's really just -- it's a relatively recent new role. It's so much -- it's just like a disclosure potential long-term commitments. It's really the maximum amount when you look at these physician contracts and employment arrangements or relocation arrangements. The accounting rules dictate that you look at the maximum payments over the life of the contract and that's the number you disclose. But you're right, the actual liability's a lot lower because that's again the maximum amount that the organization would ever have to fund.

Whit Mayo - Robert W. Baird & Co. Incorporated, Research Division

Yes. And I guess, obviously, this adds a layer of cost to your operating cost. It adds a layer of cost to your cost structure now. And I guess I'm trying to get a sense of what the annual P&L cost is now and maybe where it was a year ago. It's just it's kind of hard to parse out what the $100 million means that's disclosed and what the real sort of operating expense is.

Trevor Fetter

Well, it's actually impossible to parse it out because you've got a cost of the employment; you've got , depending on the type of physician it is, you may have basically no revenues associated with physician, but you typically have revenues in the practice; and then to the extent that physician is directing patient volumes into your hospital you didn't have before, you have revenues associated with that. So it's really something that is, it's impossible to break out and it would be very difficult to actually do it and attribute all those patients. Again, remember you've got employed hospitalist, you've got employed medical -- chief medical officers in the hospitals. You've just got a wide range of different kinds of physicians in that employment category.

Operator

Ladies and gentlemen, since there are no further questions, that concludes the Q&A portion of our event. I'd now like to turn the presentation over to Mr. Trevor Fetter for closing remarks.

Trevor Fetter

Great. Well, thank you, operator, and I'm glad we were able to take everybody's questions and get it done within an hour. And if you have any follow-up questions, please feel free to give us a call. Thanks.

Operator

Ladies and gentlemen, that concludes today's conference. Thank you for your participation. You may now disconnect. Have a wonderful day.

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