Tenet Healthcare (THC) Q4 2016 Results - Earnings Call Transcript

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Tenet Healthcare Corp. (NYSE:THC) Q4 2016 Earnings Call February 28, 2017 10:00 AM ET

Executives

Trevor Fetter - Tenet Healthcare Corp.

Daniel J. Cancelmi - Tenet Healthcare Corp.

J. Eric Evans - Tenet Healthcare Corp.

Jason B. Cagle - United Surgical Partners International, Inc.

Stephen M. Mooney - Conifer Health Solutions LLC

Analysts

A.J. Rice - UBS Securities LLC

Joshua Raskin - Barclays Capital, Inc.

Sheryl R. Skolnick - Mizuho Securities USA, Inc.

Whit Mayo - Robert W. Baird & Co., Inc.

Kevin Mark Fischbeck - Bank of America Merrill Lynch

Ralph Giacobbe - Citigroup Global Markets, Inc.

Brian Gil Tanquilut - Jefferies LLC

Scott Fidel - Credit Suisse Securities (NYSE:USA) LLC

Gary Lieberman - Wells Fargo Securities LLC

Ana A. Gupte - Leerink Partners LLC

Operator

Welcome to the Fourth Quarter 2016 Tenet Healthcare Earnings Conference Call. My name is Laurin, and I'll be your operator for today's call. At this time, all participants are in a listen-only mode. Later, we will conduct a question-and-answer session. The slides referred to in today's call are posted on the company's website. Please note the cautionary statement on forward-looking information included in the slides.

I will now turn the call over to Trevor Fetter, Tenet's Chairman and Chief Executive Officer. Mr. Fetter, you may begin.

Trevor Fetter - Tenet Healthcare Corp.

Good morning, everyone, and thank you for joining us today. We posted a slide presentation to our website yesterday which provides details on our performance during the fourth quarter in the year. I'll start today's discussion with some of our strategic and financial highlights which are illustrated on slides 3 to 6.

In 2016, we continued to make progress on our enterprise growth strategy. We enhanced our care network and refined our portfolio, both within our hospital and ambulatory operations. This included strategic expansion projects and asset divestitures. Critical service lines within our hospitals performed well overall, and we added access points, including ambulatory facilities and new models like micro-hospitals.

Disciplined cost controls helped us to drive efficiencies and mitigate expense growth while delivering great quality and service to our patients. We grew our relationships with health systems and physician partners, and we continue to broaden Conifer's client base through cross-selling opportunities and new engagements.

I'm pleased to report that 2016 marked our 12th consecutive year of EBITDA growth. We closed out the year with adjusted EBITDA of $2.413 billion, which was an improvement of 6% over last year. Adjusted EBITDA was within the outlook range we established at the beginning of the year but a shortfall in our health plan operations caused our final results to be below the midpoint. As a reminder, we are exiting that business.

As discussed on our November earnings call, volume growth in the fourth quarter was pressured by the impact of Hurricane Matthew, which affected more than a dozen hospitals and 50 outpatient centers for at least one or more days. Our out-of-network status of Humana also challenged volume growth during the quarter.

Our relationships with commercial insurers are otherwise strong as evidenced by a new long-term contract we entered into with United and Centene during the quarter. And in our overall managed care book of business, we've completed contracts covering nearly 90% of our expected commercial revenue for 2017 and over 70% for 2018.

We continue to generate top line growth in our hospitals and ambulatory operations on a same-store basis. In our hospitals, demand for higher acuity services drove increases in same-hospital patient revenues and revenue per adjusted admissions. We delivered growth in cardiothoracic and cardiovascular procedures, as well as neurosurgery and trauma. Enhancing trauma capabilities and providing our communities with additional access points for complex emergency care have been priorities for Eric and his team.

I'm pleased to report that we expect to have at least five additional hospitals elevated to level 2 trauma designations or higher by the end of 2018, adding needed advanced trauma care services in these communities. We currently have 10 hospitals with either a level 1 or level 2 trauma designation, so this represents a 50% increase in a very strategic service line.

In our Ambulatory business, same facility, system-wide revenue grew nicely at 6% and Conifer delivered revenue growth of nearly 5%, driven by a 16% increase in third party revenue.

Our hospital operators did a good job managing expenses during the year. We focused on reducing excess patient days, improving labor management, and reducing corporate costs. We also lowered supply cost by in-sourcing our supply chain operations and changing our group purchasing organization.

Both our Ambulatory and Conifer businesses delivered annual results ahead of the outlook we provided at the beginning of 2016. In the fourth quarter, Ambulatory EBITDA grew by 16%. And I want to recognize the team's work in driving growth not only in 2016 but during the entire period of our ownership as well. This includes broad-based growth across every key metric in both years.

Recently, more attention is being paid to the ambulatory space given consumer migration to this setting and the inherent high-growth opportunities. USPI is a premier provider of ambulatory services, and we have the right strategy in place to capitalize on this trend going forward.

Our portfolio of alternate care sites is now comprised of nearly 500 facilities, including over 270 ambulatory surgery centers and surgical hospitals. It also includes over 20 micro-hospitals and free-standing emergency departments. And we plan to open an additional 10 to 15 of this innovative types of facilities over the next two years.

Our micro-hospitals provide emergency services in new locations that are more convenient for our patients. Unlike a free-standing ED, micro-hospitals also have in-patient beds where we can observe and care for patients overnight if needed. We also plan to open 12 to 15 new urgent care centers this year.

Adding access points to complement our hospitals and ambulatory operations remains a key element of our growth plan. And our strategy enables us to meet patients where they are, providing them with multiple channels for care in convenient locations.

Conifer passed an important milestone last year, achieving annual revenues of more than $1.5 billion. EBITDA in the fourth quarter was $72 million, representing growth of 18%. Conifer also diversified its client base through new and expanded engagements. We continued to onboard hospitals into our revenue cycle management operations from clients like Verity Health, as well as through our 2015 expansion agreement with Catholic Health Initiatives. In our value-based care business, we recently announced an engagement with Alameda Health, where we will be providing support services to manage the health of high-risk patient populations.

As you know, we've done a lot of work over the last several years to increase the proportion of our revenue from higher margin, higher free cash flow generating businesses and enhance the mix of revenue and EBITDA that come from operations, less reliant on government healthcare programs.

In 2014, we derived roughly 15% of our EBITDA from the combination of Conifer and our then relatively small ambulatory operation. Now, two years later, our Ambulatory and Conifer segments generated roughly 37% of our 2016 EBITDA, thanks in large part to our addition of USPI.

Dan will discuss our long-term EBITDA growth targets by segment but I would just note that as our mix continues to shift to these faster growing businesses that are less reliant on government programs reimbursement, the overall weighted long-term growth outlook and sustainability of that growth for Tenet should increase.

We've also been taking steps to further reduce risk in our business and improve our portfolio through the divestiture of certain non-core operations. This is in keeping with our longstanding strategy to improve margins, grow free cash flow and increase the percentage of our hospitals with market leadership positions.

To that end, we continue to move forward with exiting our health plan business. And we've signed definitive agreements for the sale of three of our plans in Arizona, Michigan and Texas. We expect those transactions will be completed over the next couple of months.

In addition, we continue to advance the process surrounding the sale of certain hospital markets. The transactions involve a few of our hospital markets where we have modest market share positions. And we've either entered into letters of intent or are negotiating purchase agreements to sell all the hospitals and any related assets in those specific markets.

I'd like to add that our overall portfolio is strong. Of course we're always reviewing opportunities to make sure that our hospitals are best positioned in the markets where we operate. But outside of the few markets we're planning to exit, we don't have any plans to sell additional hospitals.

As we've stated previously, we expect to use the cash raised from asset sales on higher returns investments across the capital structure, which could include debt repayment, accelerating our purchase of USPI, repurchasing shares or some combination of those.

Before I conclude, I'd like to comment briefly on our outlook. We expect to deliver adjusted EBITDA of $2.5 billion to $2.6 billion in 2017. We expect our hospitals to contribute roughly 61% of our adjusted EBITDA with our Ambulatory business and Conifer accounting for 28% and 11% respectively.

As I've outlined on previous calls, we expect capital expenditures to be roughly $150 million lower this year in a range of $700 million to $750 million. By this summer, we will have completed the last of four major hospital projects which will bring our overall CapEx down this year. These projects which include a new state-of-the-art teaching hospital in El Paso, Texas will add capacity, enable us to address unmet needs in our communities, and better serve patients in four of our largest markets.

Finally, our outlook reflects our expectation that we will generate between $600 million and $800 million in adjusted free cash flow this year. Improving the cash generating power of Tenet has been a top priority for some time. I'm confident that the strategies we have in place are the right ones to help us grow free cash flow not only this year but in the years ahead as well.

And with that, let me turn the call over to Dan Cancelmi.

Daniel J. Cancelmi - Tenet Healthcare Corp.

Thanks, Trevor. And good morning, everyone. I'd like to start with a high-level summary of our financial results. We generated adjusted EBITDA of $2.413 billion in 2016, with $613 million in the fourth quarter, which was $12 million below the midpoint of our outlook range as a result of greater-than-anticipated losses at our health plans.

Adjusted EPS was $1.04 in 2016 and $0.06 for the quarter. Same-hospital patient revenues grew 4.8% for the year and 3.2% for the quarter. Adjusted EBITDA in our Hospital segment was $1.521 billion in 2016 and was up 10% after adjusting for acquisitions, divestitures, and an expected decline in health IT incentive payments.

Revenue in the Ambulatory segment increased 9.6% on a same-facility system-wide basis in 2016 and grew 5.9% in the quarter. Adjusted EBITDA increased 25.8% on a pro forma basis to $615 million in 2016. After subtracting $220 million of facility-level NCI, EBITDA less NCI increased 14.2% to $395 million in 2016 and was up 4.5% in the quarter.

Conifer's EBITDA increased 4.5% to $277 million in 2016. For the quarter, Conifer's EBITDA increased 18% to $72 million. And adjusted free cash flow of $380 million in 2016 was lower than our outlook range of $400 million to $600 million.

There were two primary reasons for the shortfall in our cash flows. First, we did not receive approximately $80 million of cash from the California Provider Fee program due to processing delays by the state. However, we have received about $70 million of the $80 million so far in 2017 and expect to receive the rest later this year.

Second, AR days increased approximately two days in the fourth quarter, resulting in a $100 million shortfall versus our expectations. We've experienced temporary payment delays related to several large payers. We are addressing this with the payers and allocating additional resources and enhancing internal processes to improve the timeliness of collections.

Turning to volumes, which are summarized on slide 7, as we discussed on our third quarter call, effective October 1 we are out of network with Humana. The change in our contracting status was the primary reason for the volume declines that we reported in the quarter for our hospitals. To give you a sense of the underlying core trends, if we exclude the volumes associated with Humana in both periods, our adjusted admissions would have increased 1.1%, and our admissions would have increased 1.3% in the fourth quarter.

Turning to cost, total Hospital segment cost per adjusted admission increased just 1.9% for the year and 1.8% in the quarter after excluding the results of the health plans from the expenses in our Hospital segment. As a reminder, medical claims associated with our health plan business are recorded on the other operating expense line. More than half of the increase in our other operating expenses this quarter was due to our health plans.

Our hospitals continue to do a good job managing labor and supplies. Labor only increased 1.7% on a per adjusted admission basis for the year and 1.8% in the quarter. Supplies were up 1.7% for the year and only 30 basis points for the quarter.

On slide 8, we were pleased that strong growth in our Ambulatory and Conifer businesses continued to have a favorable impact on bad debt and uncompensated care expense.

Moving to our Ambulatory business on slide 9, we delivered 9.6% revenue growth in the year and 5.9% in the quarter. Our case growth and revenue per case growth were strong in 2016, increasing 5.2% and 4.2% respectively. You'll notice on slide 9 the cases increased 1.7% in the fourth quarter, which was softer than recent quarters. You can attribute 230 basis points to the Humana contract status and 160 basis points to one less surgical day in the quarter.

On slide 10, I'd like to highlight that our adjusted EBITDA less facility level NCI increased 14.2% last year to $395 million, and was up 4.5% in the quarter.

As you can see on slide 11, Conifer grew revenue 11.2% to $1.571 billion in 2016 and close to 5% in the quarter. EBITDA was $277 million for the year and $72 million in the quarter with EBITDA margins of 17.6% and 17.9%.

Slides 12 and 13 provide the details of our outlook. I will start with our long-term growth expectations. Consistent with the targets that we outlined in our fourth quarter call last year, we continue to believe that we can drive 3% to 5% long-term EBITDA growth at our hospitals and we expect our Ambulatory business to grow EBITDA less NCI by 8% to 10% over the long run.

Conifer's growth in recent years has been impressive with EBITDA more than doubling since 2013. We recently reassessed the growth potential of the revenue cycle marketplace, and due to a number of factors including legislative uncertainty and the pace of providers deciding to outsource the revenue cycle functions, we are projecting a more conservative long-term EBITDA growth rate for Conifer of 5% to 7%.

In 2017, we anticipate producing total company adjusted EBITDA of $2.5 billion to $2.6 billion, up 2% to 6% excluding the health plan losses in both years.

Our outlook for 2017 excludes roughly $30 million of projected losses that we anticipate our health plans will generate this year before we sell or otherwise wind down these operations.

I also want to point out that our outlook does include the projected revenue and EBITDA from the hospitals that we are planning to divest. We will update our outlook for divestitures once we have more visibility into the timing of the transactions.

This year, we anticipate generating $1.05 to $1.30 of adjusted EPS. We are forecasting interest expense of roughly $1.03 billion, depreciation and amortization expense of $860 million to $880 million, and non-controlling interest expense of $390 million to $410 million.

Roughly two-thirds of our NCI expense is related to health systems and physicians that own a portion of USPI surgery centers or surgical hospitals. Our expectation is that as USPI grows, NCI expense in the Ambulatory business will continue to grow. And the same can be said for the NCI expense in our Hospital and Conifer segments.

For modeling purposes, we should assume NCI expense continues to grow each year. In our Hospital segment, we expect to generate same-hospital net patient revenue growth of 2% to 4%. Most of these will be driven by revenue per adjusted admission growth of 2.5% to 3.5%. On the volume side, we anticipate admissions and adjusted admissions to be in the range of positive 1% to negative 1%. This range will reflect a number of variables including a range of potential outcomes with Humana.

In our Ambulatory segment, we anticipate same facility system-wide revenue growth of 4% to 6%. This is comprised of 2% to 3% volume growth and 2% to 3% revenue per case growth. We anticipate EBITDA less facility level NCI growth of 11% to 14%. And on Conifer, we anticipate generating EBITDA of $280 million to $290 million.

Conifer's projected growth in 2017 is being affected by three primary factors. One, the wind down of Tenet's health plan business eliminates revenue and EBITDA that Conifer's value-based care business generates from our health plans. Two, startup costs from the Verity and WellStar contracts and additional resources to drive greater cash flow performance for our hospitals.

Adjusting for these factors, Conifer's EBITDA growth in 2017 is expected to be in line with our long-term growth targets. Turning to cash flow, we anticipate generating $600 million to $800 million of adjusted free cash flow which reflects our expectations for continued EBITDA growth and lower capital expenditures. After making an estimated $280 million to $320 million of cash distributions to minority partners, we expect to have $320 million to $480 million of cash this year to deploy, which is about $3 to $5 on a per-share basis.

Our priorities for this capital in 2017 are to invest $100 million to $150 million in growing our Ambulatory business and to use $320 million to $340 million to buy 12.5% of USPI which will increase our ownership to approximately 69%. As planned, we anticipate investing another $900 million to $1 billion over the next few years to own 95% of USPI. We intend to fund these payments with free cash flow generation or existing cash on hand.

As a reminder, increasing our ownership interest in USPI will result in a corresponding reduction in the redeemable NCI on our balance sheet. As of December 31 of last year, a little more than half of our $2.4 billion of redeemable non-controlling interest on the balance sheet is related to Welsh Carson and other minority partners, 43.7% ownership stake in USPI.

And as we think about our goal of reducing our debt-to-EBITDA ratio to 5 times or less, we now expect to achieve this in 2019, or possibly sooner depending on the level of asset sales and how we decide to redeploy the capital that is raised.

I'd now like to spend a few minutes helping you understand how we are thinking about our earnings progression this year. We expect our EBITDA will be heavily weighted toward the fourth quarter since we do not anticipate being able to recognize any revenue from the new California Provider Fee program until CMS approves the program, which we expect will occur late in the year.

As you may recall, in December of 2014 CMS approved the previous three-year program retroactive to January 1 of that year. That program expired on December 31, 2016. CMS has not yet approved the new 30-month program which is expected to run from January 1 of this year to June 30 of 2019.

Last year, we recorded $57 million of revenue from the program in the first quarter and $232 million for the full year. Our outlook for 2017 assumes $220 million to $230 million of revenue from the program, all of which will be recognized in the fourth quarter this year.

This is the key reason why we are anticipating only $475 million to $525 million of EBITDA in the first quarter. Please note that our results in the first quarter of last year also included $25 million of EBITDA from the Atlanta-area hospitals that we sold on March 31 last year. In addition, we anticipate the first quarter of this year will include approximately $10 million of start-up losses in our new hospital in El Paso.

To summarize, in 2016 we produced 4.8% same-hospital patient revenue growth, 9.6% revenue growth in our Ambulatory business and a little over 11% revenue growth at Conifer, all of which drove EBITDA growth of 6%. Finally, we are confident we have the right strategies in place to deliver growth in each of our businesses this year and over the long-term.

With that, I'll now ask the operator to assemble the queue for our Q&A session. Operator?

Question-and-Answer Session

Operator

Thank you. We will now begin the question-and-answer session. A.J. Rice with UBS is on the line with a question.

A.J. Rice - UBS Securities LLC

Thanks. Hello, everybody. I appreciate Dan's comments about the year-to-year change in the first quarter and taking that into account. If we look at your first quarter guidance though and try to extrapolate that to the full year, what are some factors we should consider there to sort of normalize that relative to the rest of the year?

Daniel J. Cancelmi - Tenet Healthcare Corp.

Hey, A.J., it's Dan. Let me address that. So, if you take the midpoint of our first quarter guidance $500 million, just annualize it, you get $2 billion obviously. As I pointed out, we will recognize about $225 million of California Provider Fee revenue in the fourth quarter, so you would add that to the $2 billion, so you're $2.225 billion.

Our Ambulatory business has a seasonality impact associated with it. And those earnings as we move through this year, consistent with recent years, are going to continue to grow and that would be probably in the neighborhood around $100 million of incremental earnings off the first quarter annualization. So now you have over $2.3 billion, $2.325 billion. We'll also see growth in our Conifer business as we move through the year.

HIT incentives. We'll recognize more incentives than we will in the first quarter. As well as this is sort of just a nuance of the payroll taxes in that the first quarter the limits are reset. And you get additional lift as you move through the year as people meet their limits on FICA or the unemployment tax limit. So, that number can be anywhere between $75 million to $100 million as you move through the year.

Our new hospital in the west side of El Paso, we're really excited about that. Just opened in January. As I mentioned, we'll have about $10 million of start-up losses. That's not unusual for new hospitals. But as we move through the year, those losses will diminish and we'll start earning a little bit of profit. And that will probably add just off the first quarter annualization another probably, I don't know, $25 million, $30 million of incremental earnings as we move through the year.

And I would tell you, listen, we're going to drive growth in our hospital business throughout the year off of the first quarter annualization, which will ultimately get us to the midpoint of $2.550 billion. But we feel good about how our earnings will progress this year.

A.J. Rice - UBS Securities LLC

Okay. Great. And maybe one follow-up. When you think about with the managed care environment, obviously you guys have restructured your portfolio. I know you have a number of national contracts, you've gone out of network on one contract. You mentioned in the prepared remarks, you've signed two others. Is anything changing in the way you're posturing the company given the streamlined and stronger portfolio and the way you're approaching managed care and vice versa or are you seeing them approach any differently, the contracting process?

Trevor Fetter - Tenet Healthcare Corp.

Thanks, A.J., it's Trevor. I would say that over the last decade, the negotiations have always become more difficult as the whole industry has been under pressure, both the insurers and the hospitals. And that's why we have pursued a very clear strategy of continuing to increase the proportion of our markets that are in leadership positions. And we're hitting sort of new highs in that metric every year.

And so we have not changed our strategy which is either we're all in or we're all out. And that includes not only hospitals, but ambulatory sites and physician practices. And so that makes for a high-stakes negotiation on both sides which has worked to our advantage. I cannot remember the last time we've been out of network for such an extended period with such a large payer. And it's not helpful for either party and I'm confident that over time this will be rectified. But as you pointed out, we had a contract with, I'll just use United as an example, that would have been naturally slated to expire this summer which we were able to renew early. And that, I think, speaks to the strength of the value proposition that we offer to large insurance companies like that and the strength of the relationship that we have with them.

So, in short, nothing has changed in our strategy. In fact, if anything, our portfolio has made us more attractive to insurance companies. And I think we are planning to continue with the strategy that we've had and it's worked well for us in the past.

Operator

Our next question comes from Joshua Raskin with Barclays.

Joshua Raskin - Barclays Capital, Inc.

Hi. Thanks. The first question, just on you guys have made some major CapEx investments over the last couple of years, starting with Detroit and New Braunfels at San Antonio, now El Paso. How are you measuring returns? Are you starting to see and maybe just even anecdotally what you're seeing in Detroit, what you're seeing in New Braunfels, what expectations are in El Paso? I'm just curious how you guys measure returns on those capital improvements and what sort of EBITDA is that generating now?

J. Eric Evans - Tenet Healthcare Corp.

Yeah. Thanks for the question. This is Eric. I'd comment a couple of things. Obviously, we measure all of our new projects very closely and we have a number of them that are just coming online. So, we mentioned El Paso open in January. The new Children's tower in Michigan opens midyear, as does our Delray tower and our Orthopedics tower in San Antonio opened in December. So, we measure that very closely to the expectations we had when we put those capital projects together. We do anticipate over time as those mature that they will be margin accretive and will help us deliver on that long-term outlook that we've committed to.

But certainly, we're excited about all those projects. You mentioned New Braunfels as well. That hospital continues to mature and we still see a lot of upside in that market as it works closely with our Baptist assets there in San Antonio. So, they are all investments that we track very, very closely. We expect them to be margin accretive over time. Of course, in total, when you look at the new hospital coming up, El Paso would obviously be negative at first but obviously quickly moving to the black. So, we're excited about all those projects. They certainly give us confidence in meeting our long-term growth expectations.

Joshua Raskin - Barclays Capital, Inc.

And, Eric, is there sort of a percentage return you guys say, okay, we're looking for 15% sort of long-term return on these investments or is it just simply the way the business works in hospitals, just replacing the hospitals that are needed, that you know this is margin enhancing that you know over time these are good investments?

Trevor Fetter - Tenet Healthcare Corp.

Let's break it into different categories, Josh, on that. And I would prefer not to get into specific hurdle rates. But some category of the projects that you mentioned were legacy commitments that were entered into as part of a bigger plan. So, for example, Detroit being probably the best example of that.

Other ones that are new incremental projects like the hospital we just opened in El Paso or the new orthopedic institute in San Antonio or the large tower that we added to our Delray Medical Center are discrete projects but have high returns and are relatively predictable and low risk because they're potentially add-ons to existing hospitals or in markets that we already serve.

And then, of course, there's the whole ambulatory factor where we have high returns and again relatively low risk because of the track record that we have and the great visibility we have in some key variables like pricing and costs in those kinds of acquisitions.

So, the hurdles that we apply to all of the new projects that we do are well in excess of our costs of capital. We, as I've mentioned before, given the current environment, we've shortened our planning horizon and do not expect to be launching new large capital dollar, long-tailed types of capital projects for the foreseeable future.

Operator

Our next question comes from Sheryl Skolnick with Mizuho Securities.

Sheryl R. Skolnick - Mizuho Securities USA, Inc.

Okay. Thank you very much. I'm going to try to force out an issues here. If we go to the first quarter guidance which I think has thrown everyone for a loop because it's really rather low consensus and it's hard to make everything foot. If we take the $613 million that you reported in the first quarter of last year, we take out the $57 million, we take out the $25 million, we take out $10 million for the start-up losses, that gets us to $521 million. So, versus the midpoint of your $500 million guidance, what is that $21 million delta comprised of? And then a follow-on question of how you're going to grow that on that base because I'd like a little more specificity, please. Thanks.

Daniel J. Cancelmi - Tenet Healthcare Corp.

Yeah. Sheryl, it's Dan. There's a couple of items. And so, you're right, the California Provider Fee, the $57 million that we had last year, Atlanta was $25 million and then our new hospital in El Paso was $10 million.

Couple of things. One, we are out of network with a large payer, that there is a component of that impacting it, as well as we had an incredibly strong quarter in the first quarter last year, acuity, surgical volumes. We were $38 million, if I recall, above the midpoint of our guidance the first quarter of last year. So, not to make excuses, but a really strong quarter, tough comp. And then we're not going to put a number out there, but there was an extra day last year for leap year. So, those items really are the key drivers.

Sheryl R. Skolnick - Mizuho Securities USA, Inc.

I guess I'm a little bit concerned as to why the acuity and those other things couldn't be sustained given what you've been investing in the business. But I think it's probably a longer conversation.

One of the things that I'm seeing and reading an awful lot about in the press, and I think you've mentioned this and you've certainly demonstrated some strong control of cost, but what role is the cost cutting that you're playing, that you've been doing, whether it be labor or management layers or restructuring the regions or whatever it might be, what role is that playing on your thought process? Is there any kind of EBITDA growth here that we can attribute to cost cutting because you didn't measure it – you didn't mention it in your bridge from the run rate to the EBITDA guide?

J. Eric Evans - Tenet Healthcare Corp.

Sheryl, good morning. This is Eric. Yes, so I'll take that question. When we look at the activities, we're taking all the time on making sure that we're providing great value to our patients and payers. We are always looking at obviously – you mentioned management layers, how we're structured, how we can continue to invest in the bedside in the most efficient way. And so that is something that we have been undertaking in recent months, and certainly we'll continue to look at.

I would tell you that certainly gives us greater confidence as we go throughout the year in how we're going to meet our numbers, because there is – there have been significant changes we've made to drive further cost improvement. I'd also say I'm very, very proud of our operators. If you look at last year in total for the year, below 2% on cost improvement. And we still think we have further to go and have visibility on how we're going to continue to really do a nice job of controlling cost. So, that's certainly part of the story as the year progresses.

Operator

Our next question comes from Whit Mayo with Robert Baird.

Whit Mayo - Robert W. Baird & Co., Inc.

Hey. Thanks. I know it's probably a little too early to comment on any of the pending asset sales, but any color that you can share on valuation parameters that you would consider as adequate guidelines to understand how you're approaching this would be really helpful. Thanks.

Daniel J. Cancelmi - Tenet Healthcare Corp.

Thanks, Whit. Well, first of all that everyone is going to be a different outcome in terms of valuations. And until we have definitive agreements, it doesn't really help any of the stakeholders, including our shareholders, to have a lot of speculation about which assets and where out in the marketplace. And so we hope obviously we have everything. We are very active. We have LOIs on some of the assets today, but not definitive agreements. And the assets we don't have LOIs, we're in negotiations on with buyers identified.

So, we feel very good about the ability to execute on this plan in 2017. But in the valuations, we'll have a range depending on where the asset is in terms of its current performance, as well as things like weather the deferred capital exist or any other extenuating circumstances in the market exists. And I think they'll be all over the map. But I would – maybe you can assume that we're going to – we should realize multiples that are in excess of where the company trades for today, I think, that's a reasonable assumption. And that's about that as much as I can give you in terms of, I think, the color today.

Whit Mayo - Robert W. Baird & Co., Inc.

No, that's helpful. And my second question is just around the Ambulatory segment. Is there any way to break out how much annual revenue shifted from the unconsolidated P&L to the consolidated P&L from buy-ups in 2016? And does 2017 contemplate any additional buy-ups? I understand the financial incentive to acquire a majority from a minority position. But I feel like historically, USPI strategy was more to deconsolidate. So, I'm just didn't you, if there's any color that you or Bill, or anyone can share?

Jason B. Cagle - United Surgical Partners International, Inc.

Hey, Whit. It's Jason. How are you?

Whit Mayo - Robert W. Baird & Co., Inc.

Good.

Jason B. Cagle - United Surgical Partners International, Inc.

Good, let me take them in the reverse, if you don't mind. We talked early last year about some consolidation activity that we did late in 2015. There was a little bit more, early in 2016, although, as you know, we constantly look at every – down to the facility level, every partnership whether it makes sense for us to consolidate or have the health system partner and to consolidate. Most of that activity was done early in 2015. So, other than a one-off facility here or there, I don't think you're going to see another big bolus of that activity like you saw before. So, you've seen it in our numbers this year. I don't think we've specifically disclosed revenue that went from basically, went from equity and earnings up to the consolidated line. I can tell you, if you look at our margins year-over-year, you can see a little bit of deterioration there and that's solely due to that consolidation.

So, it gives you a sense of the magnitude, which is not huge. But, again, I don't think you'll see a big chunk of those consolidations again.

Daniel J. Cancelmi - Tenet Healthcare Corp.

And Whit, It's Dan. The same facility system-wide revenue growth numbers we gave you that includes consolidated as well as unconsolidated. So, whether it shifts or not, those metrics aren't impacted by that.

Operator

Our next question comes from Kevin Fischbeck with Bank of America.

Kevin Mark Fischbeck - Bank of America Merrill Lynch

Great. Thanks. I guess the other three hospital companies so far have talked about better volume growth in 2017 than what they saw in 2016. You're looking for something a little bit less but my guess is that Humana impacts that. I guess what would your guidance for volume be ex-Humana for 2017? And is there anything else that kind of impacts your views on the volume outlook?

Daniel J. Cancelmi - Tenet Healthcare Corp.

Kevin, it's Dan. Certainly, when we came up and concluded what the appropriate guidance range would be from a volume perspective this year, the Humana situation, obviously, was taken into consideration. In terms of, we believe that our volume growth on an adjusted admission basis would be positive, absent out of network situation.

Kevin Mark Fischbeck - Bank of America Merrill Lynch

Okay. And then, I guess you mentioned that with these asset sales, that you look at debt paydown, buying USPI or share repurchase. Could you give any color about what the thought process is? I know you mentioned the target of 5 times by 2019 but I mean, I guess how do you think about balancing all of those things?

Trevor Fetter - Tenet Healthcare Corp.

Hi, Kevin. You know what we plan to do is really evaluate at the time that we have the transactions completed and have the proceeds, what those best uses are. And, of course, the capital markets have been so fluent that if you were to have asked that question basically at any point in time over the last three months, the answer would likely have been different. So, we think rather than speculating now because the timing is still a bit fluid and the transaction proceeds are material enough, that it will make a difference. That will just – will engage in active disclosure as the transactions go into definitive agreements and then make those determinations as we go.

Operator

Our next question comes from Ralph Giacobbe with Citi.

Ralph Giacobbe - Citigroup Global Markets, Inc.

Thanks. Good morning. Can you guys just go into a little bit more of the issue around the AR buildup? How many payers is it and any details around why the delay and I guess your comfort and ability to kind of recapture that $100 million shortfall?

Daniel J. Cancelmi - Tenet Healthcare Corp.

Hey, Ralph, it's Dan. Let me start with that, and then I'll turn it over Steve, and he can provide additional color. Either temporary delays. Let me be clear. We're going to get this back. It is with several payers. It's more than one or two. But we were on it. We're allocating additional resources to speed up the collection on these accounts. As I mentioned in the remarks, our DSOs, went up two days in the quarter. But we feel confident we're going to get that back in 2017. Steve, do you want to add anything else?

Stephen M. Mooney - Conifer Health Solutions LLC

Yeah. Dan. Thanks. Hey, Ralph. Yeah. So, the drivers on the shortfall, in Tenet, were both on internal and external. As you know, Tenet is our largest client. And with that we had payer processing issues, the impact is pretty significant on our operations. On this case, because of acuity increases we saw on Tenet last year, the shift from traditional Medicare to managed Medicare in specific markets and with ICD 10, we actually saw a doubling of additional information requests from the payers to the tune of 34,000 requests to 68,000 requests last year alone.

The internal part was that we frankly did not respond to the change quickly enough. But we have now, we've added the necessary resources. We made process changes to handle the increase, our work internally with the managed care partners with Clint Hailey and his team to try to change the behavior on the behavior side and on the payer side and we're confident we're going to get this number back.

Ralph Giacobbe - Citigroup Global Markets, Inc.

Okay. That's helpful. And then just switching gears. Was there any impact to the pricing stat from Humana out of network? And maybe more broadly, can you just give us a sense of how much out of network makes up of total commercial today versus maybe a year ago?

Daniel J. Cancelmi - Tenet Healthcare Corp.

Ralph, it's Dan. In terms of the out of network piece of the business, it's relatively small. It's not material. As we mentioned on our third quarter call, the Humana volumes in total were about 3%, a little less than 3%. And a lot of that business was government business. So, the commercial component of Humana, it's not the majority of our Humana business.

Operator

Our next question comes from Brian Tanquilut with Jefferies.

Brian Gil Tanquilut - Jefferies LLC

Hi. Good morning. Dan, do you mind just giving us some color on what the issues are with AR. I mean, is there anything to call out for the two-day increase and are you seeing anything different from the payers in terms of collections?

Daniel J. Cancelmi - Tenet Healthcare Corp.

Brian, it's Dan. You may not have heard my response a few seconds ago. But DSO did go up two days in the quarter. We'll get that back. It's there are temporary delays with several large payers. We're adding additional resources to address it. And Steve is here and he can give maybe condensed version of your previous version.

Stephen M. Mooney - Conifer Health Solutions LLC

Yeah. Yeah, Brian. It's Steve. I just mentioned a second ago. Ralph just asked this question. We saw some payer shifting behaviors over the course of the past year. A lot to do with some of the things around Tenet's (48:03) acuity shifting from Medicare or managed Medicare to traditional and also ICD 10. A lot more requests coming from the payers, up double digit in the course of 2016 and additional resource. The good news is we're actually ahead of cash targets for 2017 to-date. So, things are moving in the right direction.

Brian Gil Tanquilut - Jefferies LLC

Okay. And then my follow-up would be surgeries were down in Q4 in the hospital, both outpatient and inpatient. So is there anything to call out there and then any new initiatives that are coming in or kicking in that would hopefully drive surgery volumes higher this year?

Daniel J. Cancelmi - Tenet Healthcare Corp.

Hey, Brian. I'll start and then I'll turn it over to Eric to address some of the strategies. But similar to the admissions and adjusted admissions statistics that we provided with and without the impact of Humana, the surgery statistics in the quarter were also impacted by the fact that we're out of network with Humana.

J. Eric Evans - Tenet Healthcare Corp.

Yeah. And I would add a couple of things there. Similar to what we've seen for quite some time, we continue to grow in the high-acuity surgeries. We continue to see pressure on the lower end surgeries that are going to an ambulatory setting. We expect that to continue. But as Dan said, without the Humana impact and we've point out the same thing that was mentioned earlier, one less surgical day, we don't feel like it was a material change in the trend or our strategy to run high-acuity surgery.

Operator

Our next question comes from Scott Fidel with Credit Suisse.

Scott Fidel - Credit Suisse Securities (USA) LLC

Thanks. First question, just on the leverage targets. You gave us the longer-term expectation, do you just have a target for leverage at the end of 2017?

Daniel J. Cancelmi - Tenet Healthcare Corp.

Scott, it's Dan. As I mentioned, we are targeting 5 times or less. We think we'll get there in 2019, maybe sooner depending on how we ultimately deploy the capital related to the asset divestitures. I would say that thinking about our leverage at the end of this year, probably we haven't put a specific number out there but it probably run 5.75 to 5.8 times.

Scott Fidel - Credit Suisse Securities (USA) LLC

Okay. Got it. Then just the follow-up question would just be just a follow-up on the Conifer and the change to the long-term EBITDA growth guidance. Can you maybe just parse out between sort of changes in the competitive environment if you've seen that, maybe some of the newer players that have come into that market like Optum360 or others, how much impact they're having as compared to just a slower sort of demand environment than you expected around the pacing of physicians looking to outsource those services?

Stephen M. Mooney - Conifer Health Solutions LLC

Hey, Scott. It's Steve. Yeah, it's actually more the latter than the beginning. The competitive marketplace, obviously, it's changed a lot in the landscape since we launched back in 2008. But that's really not causing the challenges right now with our long-term growth targets. It really is more a factor of the marketplace. There's few very deals done. I mean, the two big deals done last year were done by us, both Verity and WellStar. We both captured those.

As we look forward to 2017, there is no doubt with the uncertainty around the ACA, there's been some, I would say, hitting the pause button from a provider standpoint. Most of you know most of our business comes from provider marketplace, and they're just kind of sitting back and kind of seeing where that's going. And then with that, they've also put some holds on some decisions around outsourcing.

So, it's really more of a factor of that and there is a factor of the competitive marketplace. I'm as bullish as I ever have been on the market, and then the space itself, we're bullish on our business plan. And I think once we get more clarity around some of these other things, I think we'll all be able to have better outlooks.

Operator

Our next question comes from Gary Lieberman with Wells Fargo.

Gary Lieberman - Wells Fargo Securities LLC

Good morning. Thanks for taking my question. Maybe if I could follow up on that last comment more broadly. Can you talk about ACA, the repeal and replace process that we're in the middle of and potential impacts to your business or areas where you're seeing potential uncertainty just because we don't know where we're exactly headed with it.

Trevor Fetter - Tenet Healthcare Corp.

Thanks, Gary. Gary, are you directing that specifically to the Conifer business or to Tenet as a whole?

Gary Lieberman - Wells Fargo Securities LLC

To Tenet as a whole.

Trevor Fetter - Tenet Healthcare Corp.

Okay. Great. Because obviously, whatever happens with health reform has implications on the revenue cycle for hospitals as well, and Conifer is well-prepared to deal with that, but it's a little hard right now to know exactly how that's going to take shape.

It's an obviously great question, tough question. We don't know. The President has said that tonight he will illuminate some of his – more details around his healthcare plan. But I think what we would look at right now is the change in rhetoric over the past several months. If we look back to November-December, it was all about we're going to repeal the ACA day one, then that morphed into repeal and replace. That has morphed into repair, and I think that's all positive for us.

Meanwhile, public opinion has improved strikingly to the point that there are three different polls out within the last week or two that are – where the favorability of the ACA – and they all defined it differently in the polls – is hitting new highs. And so, I think you have Washington recognizing that the American public does not want to lose their health insurance. However, they have conflated healthcare with Obamacare and they are concerned about rising prices and network adequacy and their ability to see their doctor and whether their doctor takes their insurance.

And so, the – and I'm not telling you anything you don't know, Congress is in a really tough spot here. But I think between the improvement in the rhetoric and the improvement in public opinion that we're probably going to see some lengthier period before we see any sort of radical changes. And Tenet, look, we are as well prepared for it as we can be in order to do well under whatever future system there is. You have to have high quality and low cost. You have to be adept at the revenue cycle, and I think we're well-positioned for all that. And as I mentioned in my prepared remarks, we've also significantly increased the proportion of our earnings that come from businesses that are far less reliant on government programs than the core hospital business.

So, we got a little bit more wait and see to do. But some of these trends are moving in the right direction.

Gary Lieberman - Wells Fargo Securities LLC

That's helpful. Thanks. And then maybe just a quick follow-up on the guidance. What's baked in there for Humana? Is it assuming that it's – you stay out of network all year or how should we think about that?

Daniel J. Cancelmi - Tenet Healthcare Corp.

Gary, it's Dan. We've certainly built into our guidance a range of – wide range of possible outcomes this year. We have – we're not going to tease out the specific number. But there is some amounts in there. Assuming we are out of network for an extended period of time, but there's also possibilities that possibly we get back into network soon and we anticipate it.

Operator

Our last question comes from Ana Gupte with Leerink Partners.

Ana A. Gupte - Leerink Partners LLC

Hi. Thanks. Good morning. I wanted to get some color on utilization trends in the first quarter and what you're observing and how that's reflected in your guidance for the first quarter. Also in the managed care side, they've been talking a lot about the pickup in flu. And I wanted to see whether you had – you're observing more ED business. Is that translating into in-patient admission at all?

Daniel J. Cancelmi - Tenet Healthcare Corp.

Hi. Ana. It's Dan. Certainly, we're not at a point where we'll talk about our January volumes. But as we've outlined in our outlook this year, we think our volume ranges will be positive 1% to down 1%. And that does include the impact of being out of network with a major payer for some period of time. So, listen, over the long-term we anticipate driving volume growth in our Hospital business. The Ambulatory business volume trends have been incredibly impressive, and we anticipate that to continue to occur as we move through this year and beyond.

Ana A. Gupte - Leerink Partners LLC

And then to follow-up on that, again on the managed care aside, they're saying the flu is a headwind but the leap day comp is more than outweighing the headwind from the flu. Any color you can give on the relevant magnitude on what you're observing on your side? And then similarly on the utilization side for the newly covered, with all the news flow that's out there on repeal and the confusion, is there more fear factor driven utilization, as that is one of the thesis going into 2017?

J. Eric Evans - Tenet Healthcare Corp.

Yeah. So, Ana, this is Eric. I would just – on the flu side, obviously, you've read the national statistics, flu is up across the country. That has varying effects on hospitals and clinics, and we see varying effects across the country as far as how prevalent it is. Obviously, we're not prepared to talk about what the impact is on Q1 volumes, but certainly, the flu season is a little later and seems to be a little stronger this year.

Operator

Thank you, ladies and gentlemen. This concludes today's conference. Thank you for participating. You may now disconnect.

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