Laboratory of America Holdings Management Discusses Q3 2012 Results - Earnings Call Transcript

Oct.18.12 | About: Laboratory Corporation (LH)

Laboratory of America Holdings (NYSE:LH)

Q3 2012 Earnings Call

October 18, 2012 9:00 am ET

Executives

David P. King - Chairman, Chief Executive Officer and President

Stephen Anderson

William B. Hayes - Chief Financial Officer, Principal Accounting Officer, Executive Vice President and Treasurer

Analysts

Thomas Gallucci - Lazard Capital Markets LLC, Research Division

Gary Lieberman - Wells Fargo Securities, LLC, Research Division

Robert M. Willoughby - BofA Merrill Lynch, Research Division

Ricky Goldwasser - Morgan Stanley, Research Division

Lisa C. Gill - JP Morgan Chase & Co, Research Division

Sylvia Chao

Kevin K. Ellich - Piper Jaffray Companies, Research Division

Dana Vartabedian - Deutsche Bank AG, Research Division

Gary P. Taylor - Citigroup Inc, Research Division

Dane Leone - Macquarie Research

Isaac Ro - Goldman Sachs Group Inc., Research Division

Operator

Good day, ladies and gentlemen, and welcome to the Q3 2012 Laboratory Corporation of America Holdings Earnings Conference Call. My name is Cheney, and I'll be your coordinator for today. [Operator Instructions] As a reminder, this conference is being recorded for replay purposes. I would now turn the presentation over to your host for today, Mr. David King, Chairman and CEO. Please proceed, sir.

David P. King

Thank you. Good morning, and welcome to LabCorp's Third Quarter 2012 Conference Call. Joining me today from LabCorp are Brad Hayes, Executive Vice President and Chief Financial Officer; Ed Dodson, Senior Vice President and Chief Accounting Officer; Adam Feinstein, Senior Vice President, Corporate Development and Strategy; and Steve Anderson, Vice President, Investor Relations.

This morning, we will discuss our third quarter 2012 financial results, update our 2012 guidance, highlight our progress on our Five Pillar Strategy and provide answers to several frequently asked questions.

I'd now like to turn the call over to Steve Anderson, who has a few comments before we begin.

Stephen Anderson

Before we get started, I would like to point out that there will be a replay of this conference call available via the telephone and Internet. Please refer to today's press release for replay information.

This morning, the company filed a Form 8-K that included additional information on our business and operations. This information is also available on our website. Analysts and investors are directed to this 8-K and our website to review this supplemental information.

Additionally, we refer you to today's press release, which is available on our website, for a reconciliation of non-GAAP financial measures discussed during today's call to GAAP. These non-GAAP measures include adjusted EPS, adjusted EPS excluding amortization, free cash flow and adjusted operating income.

I would also like to point out that we are making forward-looking statements during this conference call. These forward-looking statements include, among others, statements about our expected financial results, the implementation of our business strategy and the ongoing benefits from acquisitions. These statements are based upon current expectations and are subject to change based upon various factors that could affect the company's financial results. Some of these factors are set forth in detail in our 2011 10-K and subsequent filings. The company has no obligation to provide any updates to these forward-looking statements, even if our expectations change.

Now Brad Hayes will review our financial results.

William B. Hayes

Thank you, Steve. On today's call, I will review 4 key measures of our financial performance: cash flow, revenue growth, margin and liquidity. I'll also update our 2012 guidance.

First, cash flow. Our cash flow remained strong. Free cash flow for the trailing 12 months ended September 30, 2012, was $723.3 million. DSO was 48 days at the end of September, an increase of 1 day sequentially and an increase of 2 days year-over-year.

During the quarter, our bad debt rate was 4.3%. Cash receipts at the end of the quarter were lower than anticipated, but we expect them to recover during the fourth quarter.

Second, revenue growth. Revenue increased 1.1% year-over-year in the third quarter. During the quarter, total company volume increased 1.4% year-over-year. There was 1 less revenue day in the third quarter compared with last year.

On a per-day basis, volume increased 3.1%, and organic volume increased 0.5%. Esoteric volume per day increased approximately 2.2% in the quarter. Revenue per requisition decreased 0.3% year-over-year. Revenue per requisition was negatively impacted by the MEDTOX acquisition and continued challenges in histology.

Third, margin. For the third quarter our adjusted operating income margin was 18.2% compared to 18.8% in the third quarter of 2011. One fewer revenue day compared to last year had a 50-basis-point negative impact on operating margin. Also, the MEDTOX acquisition negatively impacted the year-over-year comparison.

Fourth, liquidity. We remain well capitalized. At the end of September, we had cash of $466 million and $1 billion available under our credit facility. During the third quarter, we repurchased $127.8 million of stock representing 1.4 million shares. Year-to-date, we have repurchased $380.4 million of stock representing 4.3 million shares.

At the end of September, $204 million of repurchase authorization remained under our share repurchase program. In August, we completed a $1 billion bond offering that consisted of 2 tranches: $500 million of 2.2% senior notes due 2017 and $500 million of 3.75% senior notes due 2022. As previously disclosed, the proceeds were used to pay the balance of our existing credit facility and for general corporate purposes.

Finally, we benefited from a lower tax rate in the quarter, bringing our year-to-date tax rate in line with the first 3 quarters of 2011.

This morning, we updated our 2012 financial guidance. We expect revenue growth of 2.5%, adjusted EPS excluding amortization in the range of $6.88 to $6.93 excluding the impact of any share repurchase activity after September 30, 2012. Operating cash flow of approximately $915 million and capital expenditures of approximately $145 million.

I will now turn the call over to Dave.

David P. King

Thank you, Brad. We are pleased with our performance given that we continue to face a very difficult economic environment. During the quarter, on a per day basis, volume increased more than 3% year-over-year and organic volume was positive. Taking into account one fewer day in the quarter, operating income margin was essentially flat.

We continue to generate strong operating and free cash flow, which we both invested in the business and returned to shareholders through share repurchase. We grew adjusted earnings per share of 9.3% and 9.8% year-to-date on a year-over-year basis, and we continued to measurably reduce selling, general and administrative expenses as a percent of revenue.

We continue to make progress on each aspect of our Five Pillar Strategy. The first pillar of our strategy is that we deploy our cash to enhance our presence in key markets and our test menu and to repurchase shares. In July, we closed our acquisition of MEDTOX Scientific, a premier forensic and clinical laboratory with a diverse test menu and a reputation for exceptional quality, dependability and customer service. We were excited about the opportunity to grow MEDTOX's specialized toxicology testing business and we welcome the talented MEDTOX employees into our LabCorp family.

The integrations of our acquisitions are going well and are in line with our expectations. We continue to realize synergies on schedule and to offer new services in genetics, oncology and esoteric toxicology. Finally, we have repurchased 4.3 million shares at a cost of $380.4 million year-to-date.

The second pillar of our strategy is to enhance our IT capabilities to improve the physician and patient experience. After a successful pilot of our Beacon Patient Portal early in the year, we expanded the rollout to 3 of our 6 divisions nationwide. The portal is a secure and easy-to-use online solution that enables patients to receive and share lab results, make appointments, pay bills, set up automatic alerts and notifications and manage health information for the entire family. We have experienced fast adoption, maintaining growth of more than 2,100 new patient registrations per week, and we remain on track to launch the portal to the remaining divisions this year.

Our electronic medical record connectivity continues to expand. We have added over 6,000 new client EMR interfaces year-to-date and are on pace to exceed our goal of 7,500 new connections in 2012. We remain committed to our open platform strategy, allowing our customers to connect seamlessly to LabCorp directly or via the EMR of their choice.

The third pillar of our strategy is to continue to improve efficiency to offer the most compelling value in laboratory services. During the quarter, we made significant progress in the rollout of our advantage positive ID system, which is now implemented in more than 40% of our core histology sites. This system standardizes workflow, eliminates waste and positively identifies specimens throughout processing.

In the fourth quarter, we will complete the rollout of our new handheld courier communication devices. This enhancement provides greater visibility in the specimen collection enables more robust route engineering and increases courier efficiency. Given the persistently weak volume environment, we continue to closely review our cost structure.

The fourth pillar of our strategy is to continue scientific innovation at reasonable and appropriate pricing. We introduce new tests and collaborate with leading companies and academic institutions to provide our physicians and patients with the most scientifically advanced testing in our industry.

During the quarter, we broadened the options for genetic carrier screening among our women's health offerings. We launched the inherent test carrier screen, which allows us to provide relevant genetic screening for many inherited diseases found throughout the pan-ethnic U.S. population. The panel represents a collection of common diseases in the U.S. general population, and we expect it to address needs for multiple ethnic-based testing scenarios. In addition, our genetic counselors will provide telephone or televideo support for patients using our inherent test carrier screening.

Sequencing is an emerging tool to support molecular diagnostics, due to the rapid evolution of next-generation sequencing technology. We are well underway in our plans to support the launch of new testing panels. The transition of current testing to this platform will offer a more comprehensive content relative to our current platforms. As part of these ongoing efforts, we participated in a recent financing round for Foundation Medicine. Foundation is a leader in the use of next-generation sequencing to assist in treatment decisions for cancer patients by looking at patient-specific molecular changes in tumors. The information is used to report targeted therapies and relevant clinical trials specific to individual patients.

The fifth pillar of our strategy is to develop alternative delivery models. We continue to discuss alternative models with managed care partners, health systems and physician groups so that we will be well positioned in the future.

As part of our BeaconLBS implementation, we are pleased to announce the introduction of our first-generation point-of-care decision support product, which interfaces with our lab test ordering system. Providing physicians with convenient point-of-care decision support tools will facilitate evidence-based test selection, helping them choose the right test for the patient at the right time. Physicians, patients and our managed care partners will benefit from this product innovation, which has been designed to improve quality and more effectively manage costs without disrupting workflow.

We have conducted 3 physician pilots in Florida, and these physician offices overwhelmingly told us that our decision support product was easy to use, beneficial to patient care and made their practices more effective.

Health systems provide outstanding lab services, but most of these businesses make a small profit or operate at a loss. Changes in test mix, reduced reimbursement from government and private payors for all services not just lab, and increasing cost of providing services make health systems more interested than they had been in the past in broad collaborations. LabCorp offers a broader test menu, greater affordability for patients and payors and the highest levels of quality and service to health systems and the communities they serve. We will continue to pursue this key initiative to offer an enterprise-wide solution that will provide health systems, patients, physicians and payors with the highest quality diagnostic testing through the lowest cost delivery model.

In summary, we are pleased with the quarter and the progress we achieved on our Five Pillar Strategy. Now, Steve Anderson will review anticipated questions and our specific answers to those questions.

Question-and-Answer Session

Stephen Anderson

Thank you, Dave. "Can you describe the impact of the Medicare reimbursement tests you will face in 2013?"

Absent any additional congressional action through the end of the year, we would anticipate an approximate 2.75% reduction to the clinical lab fee schedule beginning January 1, 2013. The Affordable Care Act baseline for the 2013 update to the clinical lab fee schedule will be a negative 0.75% effective January 1, 2013 based upon the recently published CPI-U and productivity adjustment figures. As part of the Middle Class Tax Relief and Job Creation Act, the clinical lab fee schedule will be re-baselined an additional 2% lower effective January 1, 2013. Separately, if mandatory sequestration is carried out, we will receive a 2% payment reduction in the clinical lab fee schedule effective February 1, 2013. Together, these reductions sum to an approximate annualized 4.75% total reduction to the clinical lab fee schedule, which represents approximately 12% of our revenue. On an annualized basis, we estimate that these reductions will lower our 2013 EPS by approximately $0.20. In addition to the reduction in the clinical lab fee schedule, mandatory sequestration will impose a 2% reduction in the physician fee schedule effective February 1, 2013. The physician fee schedule represents approximately 2% of our total revenue. On an annualized basis, we estimate that this reduction will lower our 2013 EPS by approximately $0.02.

"Can you update us on the mix of your business coming from esoteric testing?"

For the year, approximately 40% of our revenues were in the genomic, esoteric and anatomic pathology categories. As we reiterated last quarter, our goal is to increase our esoteric test mix to approximately 45% of our total revenue within the next 3 to 5 years.

Now, I'd like to turn the call back over to Dave.

David P. King

Thank you, Steve, and thank you very much for listening. We are now ready to take your questions.

Operator

[Operator Instructions] Your first question comes from the line of Tom Gallucci with Lazard Capital Markets.

Thomas Gallucci - Lazard Capital Markets LLC, Research Division

I guess, just first question. With all the focus on volumes these days, Dave, do you guys have a view or what is your view toward sort of what underlying market growth is out there?

David P. King

I think it would be hard to characterize underlying market growth just given all of the -- actually, I'd put all the different sites of care. Obviously, the market is growing more slowly than it has historically. I'd just -- I'd be reluctant to put a specific number on it. But my general sense from colleagues and peers is that the rate of growth has definitely slowed and that the growth rates that you're seeing from independent labs across the board is probably somewhat impacted by shifting in sites of care, particularly hospital acquisitions of physicians. So what you're seeing in terms of growth and obviously, you're not seeing hospitals reporting public -- publicly reporting their lab numbers. But what you're seeing in terms of overall market growth is somewhat impacted by just shifting in market dynamics.

Thomas Gallucci - Lazard Capital Markets LLC, Research Division

Right. Okay. and then maybe on that topic as a follow-up, since the physician employment by hospital seems to be shifting to the lab testing over, what's sort of your sense -- I guess, there seems to be 2 pieces of this equation here. What's your sense of sort of where we are in that shift? But number 2, you also mentioned, I think, in your prepared remarks that health systems are maybe more interested in working with you or others to sort of put that testing in the most efficient setting. So where are we on both of those sides of the equation?

David P. King

I think there has been really over the last couple of years a sizable movement toward hospital acquisition of physician practices, and we certainly see it in the marketplace. It started with what I would characterize as smaller practices. And now it's probably more moved into midsize practices. There's also a lot of consolidation going on even among physician practices. And when physicians consolidate their practices to get scale, many of them think about a physician office lab to do some on-site testing. So that has been I would say an accelerating trend. Is it -- I've seen numbers thrown around that say 50% of physicians work for hospitals or 50% of new physicians coming out of medical school are going to work for hospitals. I think those numbers are on the high side. But there's definitely movement toward more hospital or health system employed or integrated delivery network employed physicians. And that's definitely -- it's -- that's a headwind. It's not a gale force headwind, but it's a headwind for us in terms of growth because we're seeing a shift in site of testing. The other side of that is, that shift in site of testing also brings a significant increase in cost of lab services. And so I think over time, there will be increasing pressure on the health systems to reduce the cost of lab services, indeed to reduce the cost of all of their non-core services, and that will be to the benefit of large, independent laboratories and certainly to our benefit.

Thomas Gallucci - Lazard Capital Markets LLC, Research Division

Just one clarification and then I'll hop off. On your revenue growth guidance, it was 2 to 3. Now it's sort of 2.5. But I know before it didn't specifically include MEDTOX. But you do sort of include some acquisitions in there generally speaking. SO how do you guys use the adjustment to guidance when you put those moving parts together?

William B. Hayes

Tom, this is Brad. It does include MEDTOX. I would say that given there's not far to go here in the quarter, that wouldn't assume much else.

Thomas Gallucci - Lazard Capital Markets LLC, Research Division

Okay. So -- but if we take that old 2 to 3, which didn't include MEDTOX, I don't think -- and now the new 2.5, which does include MEDTOX, did you shift your underlying expectations at all or how do we think about that piece of it?

William B. Hayes

Yes, I think if you went back and looked from the original guidance and as you say, let's go back to the second quarter guidance, it was 2 to 3 excluding. If we're now 2.5 including, and it's pretty easy to do the math on what MEDTOX is likely contributing about 1 point there, so that 2.5 is 1.5 excluding any acquisitions, any major acquisitions like a MEDTOX. So yes, I'd say we're below that 2 to 3 from the second quarter.

Thomas Gallucci - Lazard Capital Markets LLC, Research Division

Okay. Good. I just want to make sure there wasn't any other moving parts.

Operator

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

Gary Lieberman - Wells Fargo Securities, LLC, Research Division

I guess, I believe one of the comments was that the average volume per testing day was up 3%. Can you maybe give a little bit more color around that?

William B. Hayes

Yes, Gary. This is Brad. Obviously it was driven by again, MEDTOX, which contributed, because of the nature of that business, a high amount of volume and also had a negative impact on price. We did also say that our organic volume, which would've excluded MEDTOX and Orchid, was 0.5% per day in the quarter. So that actually, and Dave mentioned this in his prepared remarks, that was better than what we saw in Q2 on an organic basis, which was I think negative 0.5%. But we do analyze the business on a per day basis. It rarely makes a difference in the quarter, but in the third quarter we needed to call it out.

Gary Lieberman - Wells Fargo Securities, LLC, Research Division

Okay. That's helpful. And then just maybe going back to the comments and the discussion around the potential opportunities for partnerships with hospitals. I guess, there's been a discussion of this for a long time. It sounds like it's coming to a head. I guess, could you maybe just anticipate kind of the rate with which opportunities or deals may happen or is this still something that is pretty kind of long term in nature?

David P. King

I think there's -- Gary, it's Dave. I think there's a much higher level of interest in collaborative models with hospitals than there has been historically. That said, these things do not move quickly. And so when you think about when does the revenue impact come from a -- when do you sit down to start having these conversations and when is there actual revenue impact -- it's not unusual particularly if there's some kind of a joint operating model, it's not unusual for transactions like this to take a year, to take 18 months to come to fruition. So in some we continue to work on, I think there's a greater sense of urgency on the health systems side now. Obviously, they're looking at some payment reductions at the first of 2013. They're looking at sequestration, same headwinds that we have. So I think I feel good about where we are in terms of capitalizing on the opportunity, but they take a while to develop.

Gary Lieberman - Wells Fargo Securities, LLC, Research Division

And then just maybe one final follow-up. Just in terms of thinking about the structure of those partnerships, would they be essentially LabCorp purchasing the business from the hospitals or would they be some kind of joint venture partnership with the hospitals? How are you thinking about that?

David P. King

I think there's a wide variety of options. Historically, we've had sizable lab management relationships with hospitals, where we run their laboratories. We've had sizable joint venture relationships, where there's an ownership percentage that the health system owns. And we've had outreach acquisitions as well. So we're flexible, and a lot of it depends on the needs of the health system when they -- when we sit down and talk to them.

Operator

Your next question comes from the line of Robert Willoughby from Bank of America Merrill Lynch.

Robert M. Willoughby - BofA Merrill Lynch, Research Division

Dave, there's a lot of focus on the near term. There's been some talk in the industry, however, about a kind of a long-term return to historical growth rate in the 5% to 6% range. Is that remotely a realistic possibility now with some of the reimbursements and other challenges you face? And if so, how and when do you get to that kind of an experience?

David P. King

Bob, I still believe that in the long term, we are a 4% to 6% top line growth industry and for a variety of reasons. I mean, first of all, the technological developments and the advances that we're making in laboratory testing are - we say we're 3% of the spend, driving 70% of the decisions. We are increasingly becoming a smaller percentage of the spend as other expenses go up at a more rapid pace. And yet we're driving more and more of the decisions. And I look at things like cancer diagnostics, next-generation sequencing technology for prenatal genetics and for target therapies for cancer patients. I look at HCV and the opportunity in the HCV screening and with the new therapies that are being developed with matching HCV patients to the right therapy. And the list just goes on and on and on in terms of where the growth opportunities are for our industry. I don't think it's any secret that right now, given a very tough economic environment and a very tough utilization environment and a lot of pressure to reduce costs, we're struggling to grow as are all healthcare services businesses really. So I'm not discouraged about the long-term as I sit and look at the things that we're working on and the opportunities that are ahead of us. Yes, I'm more encouraged than ever about the long-term and about being able to return to 4% to 6% growth. But I think I've been pretty clear that it's not going to be next year, and we should start to see some improvement in 2014 and in the years beyond. And a lot of what we're doing in terms of capital investments and IT investments and investments in partnerships is building the platform for what -- where we think the business is going to go on in the future when we do return to that growth environment.

Robert M. Willoughby - BofA Merrill Lynch, Research Division

Do you think you're well positioned if it's this higher-end testing opportunity, which I agree with you is significant, but can it really offset some of the hospital insourcing and histology challenges? I mean, you mentioned a few things here. Do you have the assets in place to enable you to grow when that market does turn? Or will this be a continued focus on deals to kind of bolster your capabilities there?

David P. King

I think we have done a great job of building ahead. I think if you look back a couple of years ago and think about the initiatives that we undertook, I mean, we've always been about efficiency in the cost structure, and we've been standardized for longer than I can remember. And when we make acquisitions, we standardize them right away and we integrate them right away. We implemented the touch system, we -- for our patient service centers to not only improve the patient experience but our phlebotomy experience. So we've made the investments in the core infrastructure, Sysmex, to make the labs run better and be at the right point from a cost perspective. We're never done with that. There's always more that one can do from a cost perspective. On the other side of the equation, where we put our capital to work, when we started saying 2 years ago that we were investing in the ability to help physicians with decision support to the point of care and better test management and test selection, we got some raised eyebrows because that's not traditionally been the role of the lab. But as you think about more and more molecular testing, physicians being more and more overwhelmed with test selection at the point of care, my view, we built exactly what we need. We're well ahead of the market in terms of the services that we offer and something that I think in the long run really has the ability to move the needle for us. And then the investments in things like next-generation sequencing, and the investment in Genzyme Genetics and all the things we've done to enhance the test menu -- even MEDTOX, which looked like a routine acquisition and in some ways is a routine acquisition, has the broadest menu in the industry of esoteric toxicology, which is going to become more and more important in things like clinical trials. And I'm sure you've not missed that drug testing in sports and athletics is getting bigger and bigger. So I think we've made all the right choices. I think we haven't been perfect. We've made some -- not every decision has been perfect -- but we made the right choices. We built the right structure. And we're where we need to be to -- when the market returns, we'll be right on the front edge of the wave.

Operator

Your next question comes from the line of Ricky Goldwasser with Morgan Stanley.

Ricky Goldwasser - Morgan Stanley, Research Division

So let me just start with just one question around the organic volume. I know that on a per diem basis, organic volumes grew 0.5%. Just that there's a lot of numbers here. So what was the -- on an actual basis, right, as reported, what would've been same store volume?

David P. King

Organic, not taking into account the extra day?

Ricky Goldwasser - Morgan Stanley, Research Division

Correct.

David P. King

Rather than trying to do this math on the phone, why don't we just take this up separately?

Ricky Goldwasser - Morgan Stanley, Research Division

Sure. Okay. So then moving onto my next question, when you think about the headwinds around Medicare reimbursement next year, I think that based on the math that you provided us, and Street numbers, it's going to cost you about 3% in growth next year. So can you talk about how you plan to offset? And I think it's built a little bit on the prior question. But really, how will you offset this headwind around reimbursement next year on the operational side? That's first. And then second, if you can give us an update just on your capital deployment strategy? I know we talked in the past about coming back to us with your plans around dividends versus buyback by year end.

David P. King

Yes. There isn't any really good way to offset $0.22 in earnings, especially when it's all price-driven because remember, it's just a -- it's a flat reduction to the clinical lab and the physician fee schedule. If it all happens, and this assumes that sequestration happens, I think the 2.75% is in the books, and that's not going to change unless Congress does something else. But if you assume both sequestration and the 2.75%, you get about $0.22 of earnings loss. And being realistic, I mean there's not a lot we can do to offset that. We've got some favorable pricing coming from other managed care contracts. We have some things that we can do on the cost side. But most of that is just -- we've got to manage the business and do the best we can to find expense savings to make up for as much of it as possible. But we're not going to make up for all of it. That's just not realistic. In terms of capital deployment, so far this year, we've returned 82% of our free cash to shareholders through share repurchase, and I feel like we've done a very nice job of that over time. We continue to study the merits of how we would allocate our capital. Obviously, continue to watch the political environment very closely because of tax rate issues that may take effect at the beginning of the year. So we don't have a final decision yet, but in the meantime we're going to continue to do what we have been doing in terms of returning value to the -- returning value and returning our cash to the shareholders.

Operator

Your next question comes from the line of Lisa Gill with JPMorgan.

Lisa C. Gill - JP Morgan Chase & Co, Research Division

Dave, I was wondering if maybe you could just give us some thoughts about how you see the lab industry post reform. There's a lot of questions about what the Affordable Care Organizations will look like and where lab testing will be done. I know you talked a lot about physicians already being owned by hospitals. But can you just talk about 2014 and where you see opportunities and maybe challenges? And then secondly, can you maybe also just size the opportunities around hospital reference labs and where do you -- how big of an opportunity do you think that is? And is there any way to quantify the number of opportunities over the next couple of years?

David P. King

Okay. I think it's too early to predict what 2014 is going to look like, Lisa. And I'm not trying to be elusive. But I think there's no -- at least from what I've seen and from what we've experienced so far with ACOs, there's very little commonality in the way that they're organized, in the way that they're structured, in their affiliations with health systems and so I think it'd be very hard to make a broad prediction about how ACOs are going to work in conjunction with labs. I think, and I won't repeat the discussion earlier on health systems and integrated delivery networks -- the need to reduce cost across-the-board. But I think that the low-cost opportunity and the low-cost -- that the low-cost providers will have great opportunity in whatever environment health care reform ends up looking like. The other side of that is a lot of the 2014 calculations are premised on a sizable population moving into Medicaid. That's premised on Medicaid expansion, and it's not clear that Medicaid expansion is going to occur or that it's affordable. So I just think 2014 remains a large question mark at this point.

Lisa C. Gill - JP Morgan Chase & Co, Research Division

And then if we think, though, about hospital reference labs and we think about the opportunity to work together, is there any way to size that opportunity for us to say, okay, yes, there's challenges over the next couple of years, reimbursement, et cetera, but there's x percent that you think out in the marketplace you could have a relationship with or work together to be able to replace some of that revenue and increase volume to offset some of the pressure on reimbursement? Is there a way for us to all think about that?

David P. King

Yes. I think there's a lot of numbers out there about how much volume is going through hospitals, how much of it is reference work versus work that has to be done in the hospitals. I guess, the numbers that I -- the single number that to me demonstrates the size of this opportunity is that according to the Medicare Trustees Report, just for Medicare, which is paid to hospitals at basically the same fee schedule that we get paid, just for Medicare, in the last Medicare Trustees Report, there was over $5 billion of lab work that went through hospitals, not in the DRG, not in Part A but just outpatient lab work that was paid off the clinical lab fee schedule that went through hospitals. So there's no revenue compression in that opportunity. There's no premium pricing for hospitals. That's just what hospitals are getting in Medicare from Medicare beneficiaries that could be redirected to independent labs, that could partially be redirected toward independent labs, there could be joint ventures around. And remember, that's where the cost differential was most noticeable to the health systems because they're not getting premium reimbursement. They're not getting multiples of what independent labs are getting reimbursed. So there's no number that I can give you that says this is what we can gain in the next 3 years or this is what we can -- this is what we'll be able to redirect. But that's number you can look at and say there's a lot of volume going through hospitals that could be more efficiently -- that could more efficiently be performed by independent laboratories, and the key is figuring out how to make the hospitals the partner in that endeavor.

Operator

Your next question comes from the line of Amanda Murphy with William Blair.

Sylvia Chao

This is actually Sylvia in for Amanda this morning. I just had a follow-up on your previous comment on HCV, David. I'm curious if you have seen any benefits of that guidance in your volume this quarter. Or how do you expect the overall benefit or impact to your volume in a short term or longer term?

David P. King

I think the HCV opportunity is a longer-term opportunity. We haven't seen anything material certainly in the quarter but the CDC recommendation is that all adults, all U.S. adults in the "baby boomer" population be screened. The key will be to get that screening done at the primary care physician point of service because that's where the education needs to take place. The HCV screen is not a hugely expensive test. That's one of the nice things about it. It's a low-cost test that can identify a long-term chronic disease with very negative health consequences. So I think we'll see it migrate into the numbers over the next 3 years. But I don't think you're going to see enormous jumps in HCV screening or HCV utilization in any one particular timeframe.

Sylvia Chao

Okay. Then I just had a follow-on on the next-gen sequencing panel you mentioned earlier. Can you give us a little more color on in terms of what PC types or are you platform-agnostic at this point and do you have a preference for desktop or large box sequencers out there?

David P. King

At this point, we're platform-agnostic, and I think the determination of is it desktop or large box sequencer depends on the model and the volume expectations. So we've actually owned a sequencing business for quite a few years now that specifically develops sequencing panels around cardiovascular disease that was built on a big box model. But I think cardiovascular, I think obviously prenatal genetics and oncology are the 3 biggest markets where we would look at the sequencing methodology.

Operator

Your next question comes from the line of Kevin Ellich with Piper Jaffray.

Kevin K. Ellich - Piper Jaffray Companies, Research Division

Just a couple of questions. First of all, could you provide any color behind what was behind the lower cash flow guidance? I think in the prepared remarks you talked about the cash receipts being lower this quarter but recovering in Q4. Just wondering also what was behind that?

William B. Hayes

Yes. Kevin, this is Brad. And it really goes back to the discussion we had earlier, I think near the beginning of the Q&A around the top line. So I mean, the cash flow generation, I think, starts with, and the reduction in our guidance, the numbers we've talked about, about our revenue guidance now being 2.5% with a point of that being MEDTOX's. So that's below our Q2 revenue guidance, which excluded MEDTOX. We had not closed at that time. So it starts there, and acquisitions don't contribute immediately the same kind of cash flow that our regular business does. So I think that's the first and foremost thing behind the cash flow revision.

Kevin K. Ellich - Piper Jaffray Companies, Research Division

Got it. Appreciate that. And then what about the cash receipts? Was that the...

William B. Hayes

Oh, sorry. Yes, that was definitely a highlight for the quarter. And as I said, we expect that to turn around in the fourth quarter.

Kevin K. Ellich - Piper Jaffray Companies, Research Division

Okay. And then, Dave, adjusted operating income's been steadily declining this year, obviously a challenging environment. Just -- you guys have done a great job over the years in cutting costs. Just wondering what can be done as we head into 2013. It sounds like you're thinking it's going to be another tough year.

David P. King

Yes. Kevin, I think that -- in some sense goes back to the question Bob asked about how we feel about the long term. So if we believed that we're going to be in a 2% world forever, then looking at geographic -- looking at lab footprint and other things would be very, very high on the agenda versus if you believe you're going to return to growth. You can cut yourself to the point where you're not ready to grow when the market returns to growth. Given that, however, and given the general environment, I mean, we are basically reviewing every dollar of expense that we spend around here and where there are opportunities for us, and that includes, as I think I've said often, our 3 biggest expenses are labor, supplies and breadth. So when you start looking at the expense base, it's facilities, it's people and it's the efficiency of your testing operation. And we're spending a lot of time looking at things that we can do to improve the cost structure without a negative impact on customer service. Again, for all the things we've done from a cost perspective over the last 3 or 4 years, we watch the customer service ratings very carefully. And our customer service ratings that we've just received for the last quarter continue to be at all-time highs for the company. So the last thing we want to do is cause a deterioration in service, which is only going to lead to further deterioration in our growth.

Kevin K. Ellich - Piper Jaffray Companies, Research Division

Exactly. Okay. And then we've seen a lot of or heard a lot from the payors about narrower network use. And then you guys are obviously the low-cost provider. Just wondering if you've seen or do you think there will be increased activity or movement by state Medicaid programs shifting to more exclusive arrangements with low-cost providers such as yourself?

David P. King

I guess if I were to identify what I think is the biggest trend in state Medicaid, it's managed Medicaid, so it's moving completely away from the idea that the states are going to run these programs and moving them instead into programs that are run by private companies. And it wouldn't surprise -- I mean again, there you're negotiating with a private insurance company just the way you are when you're negotiating a health system -- sorry, when you're negotiating a standard contract. I wouldn't be surprised to see that continue. Medicaid is not a -- does not pay particularly high rates, Kevin. And they pay -- there is no premium -- there is sort of no in-network -- out-of-network. There's no premium for people who are out of network the way there are with some of the managed care plans. SO I don't know about narrower network so much as I think about ways in which they can just reduce the overall unit cost.

Operator

Your next question comes from the line of Darren Lehrich with Deutsche Bank.

Dana Vartabedian - Deutsche Bank AG, Research Division

This is Dana Vartabedian in for Darren. Can you comment on whether or not you've experienced any sort of pricing pressure in anatomic pathology, I guess, especially as it relates to prostate? And if you can, about how much of your pathology business does prostate represent?

David P. King

I don't think we've experienced pricing pressure. As we've talked about historically, the physician in-sourcing has been volume pressured. But I don't think we've experienced pricing pressure and nothing specific with respect to prostate biopsies, no.

Dana Vartabedian - Deutsche Bank AG, Research Division

All right. And can you tell me about how much of the pathology business that makes up?

David P. King

I could not tell you off the top of my head, sorry.

Operator

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

Gary P. Taylor - Citigroup Inc, Research Division

A few quick questions. Brad, this is, I guess, the third year in a row where that 3Q tax rate is kind of lower than the other quarter. So obviously, that's starting to look like pretty recurring. Would that be your expectation for 2013 as well?

William B. Hayes

Yes.

Gary P. Taylor - Citigroup Inc, Research Division

Okay. And that's just seasonal state or...

William B. Hayes

Well, yes, Gary, and it really goes back to, without getting into a lot of discussion about accounting, the adoption of FIN 48 which was several years ago. It really has led to your observation.

Gary P. Taylor - Citigroup Inc, Research Division

Got it. And then you guys commented that both MEDTOX and histology were the drivers of the negative aggregate revenue per requisition. Can you quantify the MEDTOX impact on that?

David P. King

No. We're just not going to break it down in that level of detail. MEDTOX because of a lot of the routine toxicology testing, employer drug testing, is a lower price point than our average price point, and that's why it created some drag.

Gary P. Taylor - Citigroup Inc, Research Division

And you'd said -- what about on margin, you'd said 50 basis points. I'm sorry, actually you said 50 basis points from the 1 less revenue per day, but you also called out MEDTOX has an impact on year-over-year margin. Can you quantify that?

David P. King

No.

Gary P. Taylor - Citigroup Inc, Research Division

Okay, I'm striking out here.

David P. King

1 of 3. You're still at the Hall of Fame numbers.

Gary P. Taylor - Citigroup Inc, Research Division

Well, that was just a yes or no question. So this last one will put me either at 250 or at the 500, I guess. I'm going to ask you the question that investors ask me the most. I know it's something that you've given some ongoing consideration to. But given the environment and the lower growth rates, one of the compelling characteristics of the business is the robust free cash flow generation and so over and over again, investors say why not a dividend? And I guess, most people would understand that the pros of giving a dividend and some of the premium valuation that's afforded the stocks that have one. Is there -- what's the obvious stuff on the counter side to why not to institute a dividend in the future?

David P. King

Well, I mean, I think you can make a convincing argument for both sides, and that's why it's not an easy answer. If it were an easy answer, it would be -- we would've answered a long time ago. I think if I think about the reasons why one would not pay a dividend, first of all, we look back to the last -- just 2008, we look back at our share repurchase and the stock is up about $20 so about 30% since the beginning of 2008. And the delta between what we've paid for the shares and the current price or the price as of the beginning of the week was another 15%. I think on a 5-year timeframe, that's a pretty impressive performance for return to shareholders based on share repurchase. And I'm not sure that you add much to that type of performance by paying a dividend. And I think that's the issue is the long-term. If you look at the last year, the last 2 years and where the stock has been, obviously you can make an easy case to say, well, you would have gotten more total shareholder return out of the dividend. But our job is to look at what's in the long-term best interest of our company and our shareholders, and it's just not self-evident that companies that pay a dividend actually maintain premium pricing over time versus share repurchase or that they end up providing a greater level of return to their shareholders than companies that use share repurchase. So those are the considerations. And again, if this were a slam dunk, we would've done it a long -- we would've made our decision a long time ago.

Operator

Your next question comes from the line of Dane Leone with Macquarie Securities.

Dane Leone - Macquarie Research

I guess the first question is, you said that because of one fewer revenue day, you had a 50 basis points operating margin impact. Is that in line with the benefit that you saw in the first quarter given the extra day and due to the leap year? Or I'm just trying to reconcile that I guess, so any color would be helpful.

William B. Hayes

Dane, if I go back to our first quarter comments, I think we said that days were approximately the same as Q1 '11.

Dane Leone - Macquarie Research

Right.

William B. Hayes

This is revenue days as opposed to calendar days so it's just how many days of revenue do you generate and the fact that there was a leap day in the first quarter doesn't necessarily lead to an additional revenue day because if you look back at the first quarter transcript, obviously, we covered this where the holidays fall and where the January 1 holiday fell this year make a difference in terms of revenue days.

Dane Leone - Macquarie Research

Got it. Okay. So a kind of macro question here, is something that we haven't touched on yet. But looking at the past 3 years or the last 2 years specifically, '11 and year-to-date this year, it's clear that there seems to be an underlying trend of lower macro utilization and we've spoken about unemployment, but something that we get a lot of questions about is around the consumer-driven health plans impacting just lower macro utilization and consumers just avoiding or being more conscientious about the testing that's done in the physician office. I'm just curious if there was any data points that you had that you either confirm, deny or shed some light onto this trend as under current healthcare law or under the health care reform, it seems like this trend is going to continue for some years as it relates back to the Cadillac tax that corporations are trying to avoid. So I'm not sure if you have any data points, but it would be helpful.

David P. King

I think the biggest data point we have is that the percentage of our billings that end up being the responsibility of the patient continue to increase and they particularly continue to increase in the first and second quarters of the year. So it's clear that consumer-driven health plans are causing patients to have more responsibility. It's clear that consumer-driven health plans are dampening utilization. Just hard to point to a statistic, but just anecdotally. I mean, if you look at the Kaiser Family Foundation studies on patients, people who were surveyed who have decided to forego care, that's a pretty compelling statistic about what the consumer-driven health plans are doing. I do think as we get to the next phase of the consumer-driven health plans, which is pricing transparency for patients, again, the lower cost, more efficient providers are going to benefit, and that's where we'll be in an excellent position.

Operator

Your next question comes from the line of Isaac Ro with Goldman Sachs.

Isaac Ro - Goldman Sachs Group Inc., Research Division

Just one follow-up question on volumes. Just wondering if you could comment on the pacing throughout the quarter, did it improve or decline when you adjust for seasonality?

David P. King

We don't talk about the pacing of volume within the quarter.

Isaac Ro - Goldman Sachs Group Inc., Research Division

Okay. And then on the Foundation Medicine investment, it's interesting technology, obviously, same timeframe and amount of uncertainty about how these tests are going to be regulated over time. So just wondering what your expectations are for how the regulatory and reimbursement process will evolve in that market in 2013.

David P. King

I think -- I don't think you'll see a lot of activity in regulatory or reimbursement with Foundation in 2013. And obviously, we're passive investors, so we're not running that business. But the reason that we invested in Foundation is because we like the technology, we like the leadership, we like the other investors and we think it has the potential to be where cancer diagnostics goes, particularly complex diagnostics, over time. So it gives us a good opportunity to get a look at how cancer diagnostics is evolving without having to make huge capital commitments within LabCorp. And that's the reason why we made that investment and look forward to seeing it evolve over time.

Isaac Ro - Goldman Sachs Group Inc., Research Division

And maybe if I can be a little more specific not just on Foundation but in the category of genetic testing in general, you have obviously a lot of changes being proposed through CMS and some of the parties with whom they work. Just wondering, again, in general, if you look at genetic testing as a category, do you have a specific view on how that market will evolve? I mean, that's obviously a source of potential upside just given the contribution of those types of tests to your business, that's why I asked.

David P. King

Yes, I mean the market clearly is going to evolve toward more genetic testing through a sequencing platform, which means that there's going to be considerable amount more information provided at a lower cost. And part of the challenge is going to be the interpretation of that information by physicians who are delivering services. But I'd just point you toward, I think it was within the last 3 weeks, there was an extensive article in the Wall Street Journal about the genetic research that's being done on autism and the sequencing methodology for the different academic institutions that are using sequencing methodology to try to get at the genetic as opposed to the environmental basis of autism. There's -- this is going to be an area that's going to continue to grow. The sequencing methodology is going to continue to grow. We've invested in it directly in our business but we also will continue investing in it through partners.

And with that, ladies and gentlemen, I think we're going to wrap it up for this morning. We appreciate your listening to our call today and hope you have a great day. Thank you.

Operator

Thank you for your participation in today's conference. This concludes the presentation. You may now disconnect. Have a great day.

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