Tenet Healthcare Corporation (NYSE:THC) reported its fourth-quarter 2024 earnings, revealing a mixed performance that saw earnings per share (EPS) exceed expectations while revenue fell short. The company posted an EPS of $3.44, surpassing the forecasted $2.95. However, revenue reached $5.07 billion, missing the anticipated $5.17 billion. In response, Tenet’s stock price dropped by 6.4% in pre-market trading. According to InvestingPro data, the company trades at an attractive P/E ratio of 4.12, with a market capitalization of $12.29 billion.
Key Takeaways
- Tenet Healthcare’s EPS beat expectations, but revenue missed forecasts.
- The stock price decreased by 6.4% following the earnings release.
- Strong performance in ambulatory surgical centers contributed to growth.
- The company plans significant investments in mergers and acquisitions in 2025.
- Tenet reported a solid cash flow generation of $1.1 billion for 2024.
Company Performance
Tenet Healthcare demonstrated robust financial performance in 2024, with full-year net operating revenues of $20.7 billion and a consolidated adjusted EBITDA of $4 billion, representing a 13% growth over the previous year. The company improved its adjusted EBITDA margin by 200 basis points to 19.3%. The fourth quarter saw continued strength, with total net operating revenues of $5.1 billion and a consolidated adjusted EBITDA of $1.048 billion, achieving a margin of 20.7%. InvestingPro analysis indicates the company maintains a GREAT financial health score of 3.56, with particularly strong profitability metrics. InvestingPro subscribers can access 8 additional key insights about Tenet’s financial strength.
Financial Highlights
- Revenue: $5.07 billion in Q4 2024, below forecasts of $5.17 billion.
- Earnings per share: $3.44, exceeding the expected $2.95.
- Full-year net operating revenues: $20.7 billion.
- Full-year consolidated adjusted EBITDA: $4 billion.
Earnings vs. Forecast
Tenet Healthcare’s EPS of $3.44 exceeded the forecast by 16.6%, reflecting strong operational efficiency. However, the revenue shortfall of $100 million, or approximately 1.9%, indicates challenges in meeting market expectations. This mixed result contrasts with the company’s trend of meeting or surpassing revenue forecasts in previous quarters.
Market Reaction
Following the earnings announcement, Tenet’s stock experienced a 6.4% decline in pre-market trading, closing at $138.83. This movement places the stock closer to its 52-week low of $87.06, indicating investor concerns despite the EPS beat. The broader market reaction suggests a cautious sentiment, likely influenced by the revenue miss. Despite recent volatility, InvestingPro data shows the stock has delivered an impressive 53.34% return over the past year. Based on InvestingPro’s Fair Value analysis, the stock appears to be trading above its intrinsic value. For detailed valuation insights, investors can access the comprehensive Pro Research Report, available exclusively to InvestingPro subscribers.
Outlook & Guidance
Looking ahead, Tenet projects an adjusted EBITDA range of $3.975 to $4.175 billion for 2025, signifying a 7% growth. The company plans to invest $250 million in mergers and acquisitions and expects to add 10-12 new ambulatory surgical centers. Guidance for USPI same-facility revenue growth is set at 3-6%, with hospital segment adjusted admissions growth anticipated at 2-3%. Analyst consensus gathered by InvestingPro suggests strong potential upside, with price targets ranging from $140 to $217 per share.
Executive Commentary
CEO Sam Satoria expressed confidence in Tenet’s future, stating, "We had an outstanding year in 2024 and believe that we are in a great position for another strong year in 2025." CFO Sun Park highlighted the company’s financial strength, noting, "We are very pleased with our ongoing cash flow generation and have a commitment to a deleveraged balance sheet."
Risks and Challenges
- Potential healthcare policy changes could impact operations.
- Revenue shortfall may signal challenges in sustaining growth.
- Macroeconomic pressures could affect patient volumes and reimbursement rates.
- Increasing competition in the healthcare sector.
- Dependence on successful integration of new acquisitions.
Q&A
During the earnings call, analysts inquired about the potential impact of healthcare policy changes and Tenet’s resilience in varying regulatory environments. Executives emphasized the company’s strong cash flow generation and commitment to share repurchases, addressing concerns about future financial strategies.
Full transcript - Tenet Healthcare Corporation (THC) Q4 2024:
Conference Operator: Good morning. Welcome to Tennant Healthcare’s Fourth Quarter twenty twenty four Earnings Conference Call. After the speaker remarks, there will be a question and answer session for industry analysts.
Sam Satoria, Chairman and Chief Executive Officer, Tennant Healthcare: Analysts.
Conference Operator: I’ll now turn the call over to your host, Mr. Will McDowell, Vice President of Investor Relations. Mr. McDowell, you may begin.
Will McDowell, Vice President of Investor Relations, Tennant Healthcare: Good morning, everyone, and thank you for joining today’s call. I am Will McDowell, Vice President of Investor Relations. We’re pleased to have you join us for a discussion of Tennant’s fourth quarter twenty twenty four results as well as a discussion of our financial outlook. Tennant senior management participating in today’s call will be Doctor. Saum Satoria, Chairman and Chief Executive Officer and Sun Park, Executive Vice President and Chief Financial Officer.
Our webcast this morning includes a slide presentation, which has been posted to the Investor Relations section of our website, tennanthealth.com. Listeners to this call are advised that certain statements made during our discussion today are forward looking and represent management’s expectations based on currently available information. Actual results and plans could differ materially. Tennant is under no obligation to update any forward looking statements based on subsequent information. Investors should take note of the cautionary statement slide included in today’s presentation as well as the risk factors discussed in our most recent Form 10 K and other filings with the Securities and Exchange Commission.
And with that, I’ll turn the call over to Sal.
Sam Satoria, Chairman and Chief Executive Officer, Tennant Healthcare: Thank you, Will, and good morning, everyone. We delivered outstanding performance in 2024 characterized by strong same store revenue growth, disciplined operations and effective capital deployment. In addition, the year was highlighted by portfolio transactions that have transformed our franchise to be well positioned for long term growth with strategic flexibility and a deleveraged balance sheet. We reported 2024 net operating revenues of 20,700,000,000 and consolidated adjusted EBITDA of $4,000,000,000 which represents 13% growth over 2023. Full year adjusted EBITDA margin of 19.3% improved over 200 basis points from prior year.
Our fourth quarter results were above our expectations driven by continued same store revenue strength, high acuity growth, as well as effective cost management. Our disciplined approach has enabled us to consistently exceed our performance expectations each quarter this year furthering our track record. I would note that our full year adjusted EBITDA ended the year over $600,000,000 higher than the midpoint of our initial expectations, driven by strong growth and operational performance. USPI had a fantastic year in 2024. We generated $1,810,000,000 in adjusted EBITDA, which represents 17% growth over 2023 and adjusted EBITDA margins of 40%.
Same facility revenues grew 7.8% in 2024, another year substantially above our long term goals. High acuity volume growth was highlighted by total joint replacements in the ASCs, up 19% over prior year. Importantly, customer service levels in our centers remain quite high as we earned a 96.6 overall patient experience score in 2024. Turning to our hospital segment, despite the sale of 14 hospitals during the year, we generated $2,185,000,000 of adjusted EBITDA in 2024, which represents nine percent growth over prior year. Same store hospital admissions were up 4.7% as we continue to open up capacity to respond to a strong utilization environment.
Acuity and payer mix were strong throughout 2024 and drove a 4.6% increase in same store revenue per adjusted admission over prior year. This was an important year for Tennant as we transformed our portfolio of businesses through the multiple high multiple sales of 14 hospitals and related operations generating $5,000,000,000 in gross proceeds and enabling significant balance sheet deleveraging. In addition, we added nearly 70 ambulatory surgical centers to the portfolio in 2024 as we were very active in both M and A and de novo development. And finally, over the past two years, we have returned capital to shareholders via share repurchase, retiring approximately 14% of our outstanding shares for $1,120,000,000 since our repurchase program began in the fourth quarter of twenty twenty two. Going forward, we plan to be active repurchasers of our shares, particularly at our current valuation multiples.
These actions have resulted in a portfolio of businesses that is more predictable, capital efficient and able to operate in a variety of environments with better margins and ample free cash flow for the benefit of shareholders. In summary, we’re very pleased with our team’s performance in 2024 and we believe that we will carry this momentum into the new year. Turning to 2025 guidance, we are projecting full year 2025 adjusted EBITDA of $3,975,000,000 to $4,175,000,000 which is an attractive 7% growth rate at the midpoint on a normalized basis. We anticipate adjusted EBITDA growth at USPI of approximately 8.5% at the midpoint of our guidance for 2025 based on our expectation of 3% to 6% growth in same facility revenue fueled by ongoing strength in demand and acuity, continuing effective operational execution and additional sites of care joining the portfolio. We intend to invest approximately $250,000,000 each year towards M and A in the ambulatory space and the pipeline of opportunities remains strong.
We anticipate adding 10 to 12 de novo centers in 2025. Our ability to consistently scale our platform to create additional low cost sites of care for patients and physicians continues to pay dividends as it improves our overall growth, profitability, capital efficiency and resiliency in this regulatory environment. Turning to our Hospital segment, we are expecting adjusted EBITDA growth of approximately 5.7% on a normalized basis at the midpoint for 2025. This projected growth is expected to be driven by 2% to 3% adjusted admissions growth and the strong operating discipline that our team has now demonstrated for many years. The hospital segment’s performance will be enhanced by strategic capital deployment, expanded service lines and further contributions from the new Westover Hills facility, which opened in the third quarter of twenty twenty four.
Additionally, as we have noted, we have expanded the relationships that Conifer has with acquirers of hospitals we’ve sold and this should contribute to growth in 2025. Finally, we acknowledge that there is currently a great deal of focus on the impact of potential regulatory changes in our space. We have demonstrated an ability to perform well in a variety of operating environments and believe we are differentiated from our peer set as we navigate potential changes going forward. For example, our ASCs operate with freestanding ASC rates, which insulates that important part of our business from potential changes in site neutrality rules. In summary, we had an outstanding year in 2024 and believe that we are in a great position for another strong year in 2025.
Our guidance reflects the opportunities before us and the momentum that we carry into the new year. Our established management team stands ready to execute our focused strategy and deliver value for patients, physician partners and in turn shareholders. And with that, Sun will now provide a more detailed review of our financial results. Sun?
Sun Park, Executive Vice President and Chief Financial Officer, Tennant Healthcare: Thank you, Sam, and good morning, everyone. We are very pleased with the strong finish to the year. In the fourth quarter, we generated total net operating revenues of $5,100,000,000 and consolidated adjusted EBITDA of $1,048,000,000 which represents an adjusted EBITDA margin of 20.7%, up almost 200 basis points from fourth quarter of twenty twenty three. For full year 2024, we generated $20,700,000,000 of total net operating revenues and consolidated adjusted EBITDA of $3,995,000,000 These results were driven by strong same store revenue growth, continued high patient acuity, favorable payer mix and effective cost controls. I would now like to highlight some key items for each of our segments beginning with USPI, which again delivered strong operating results.
In the fourth quarter, USPI’s adjusted EBITDA grew 14% over last year with adjusted EBITDA margin at 42.1%. USPI delivered an 8.6% increase in same facility system wide revenues driven by high acuity levels and favorable payer mix. Same facility system wide surgical case volume grew slightly over last year. And turning to our Hospital segment, fourth quarter adjusted EBITDA was $518,000,000 with margins up 90 basis points over last year at 13.6%. Normalized for the divested hospitals, adjusted EBITDA grew 13% over fourth quarter of twenty twenty three.
Same hospital inpatient admissions increased 5% and revenue per adjusted admission grew 0.6%. Our consolidated salary, wages and benefits in fourth quarter of twenty twenty four was 41.3% of net revenues and our consolidated contract labor expense was 2.1% of SWV, both substantially lower than the 43% and the 2.8% respectively that we reported in the fourth quarter of twenty twenty three. Next (LON:NXT), we will discuss our cash flow, balance sheet and capital structure. Our cash flow performance was very strong in ’twenty four with $1,100,000,000 of free cash flow for the year. This includes the payment of $855,000,000 in income taxes related to our completed divestitures.
Excluding these tax payments, this represents nearly $2,000,000,000 of free cash flow for the year or $1,300,000,000 of free cash flow after distributions to non controlling interests
Ann Hynes, Analyst, Mizuho (NYSE:MFG): or
Sun Park, Executive Vice President and Chief Financial Officer, Tennant Healthcare: NCI. For full year 2024, we repurchased 5,600,000.0 shares of our stock for $672,000,000 We finished the year with over $3,000,000,000 of cash on hand with no borrowings outstanding under our $1,500,000,000 line of credit facility. Our year end leverage ratio was 2.5 times EBITDA or 3.2 times EBITDA less NCI, a substantial improvement over the past year, reflecting the proceeds that we received from our hospital divestitures as well as our outstanding operational performance. We are very pleased with our ongoing cash flow generation and have a commitment to a deleveraged balance sheet. We believe we have significant financial flexibility to support our capital allocation priorities and drive shareholder value.
Let me now turn to our outlook for 2025. We expect consolidated net operating revenues in the range of $20,600,000,000 to $21,000,000,000 Our projected consolidated adjusted EBITDA is in the range of 3,975,000,000 to $4,175,000,000 As a reminder, there are two normalizing items that I would call out when comparing our $25,000,000 adjusted EBITDA to the prior year. First, we reported $114,000,000 of adjusted EBITDA from facilities that we divested in ’24 and will not recur. Additionally, we reported $74,000,000 of out of period supplemental Medicaid payments in Michigan and Texas in 2024. After normalizing for these items, our ’25 adjusted EBITDA is expected to grow seven percent at the midpoint of our range.
Our ’25 outlook assumes continued growth in same store volumes and effective pricing as well as strong operational efficiencies and disciplined cost controls. Additionally, we anticipate further contributions from recent investments and partnerships in the hospital segment, as well as from M and A and de novo center openings at USPI. In addition, we are also assuming the following: same hospital admissions growth of 2% to 3% and adjusted admissions growth of 2% to 3% and for USPI, same facility revenue growth of 3% to 6%. On a normalized basis, we expect adjusted EBITDA to grow 8.5% at USPI and 5.7% for our Hospital segment at the respective midpoints of our guidance ranges. Our outlook also assumes $35,000,000 of net revenues from the Tennessee supplemental Medicaid programs.
About one third of this increase is related to the second half of twenty twenty four and is expected to be recorded in the first quarter of this year. Finally, we would expect first quarter twenty twenty five consolidated adjusted EBITDA to be in the range of 24% to 25% of our full year consolidated EBITDA at the midpoint. We anticipate that USPI’s EBITDA in the first quarter this year will be 21% to 22% of our full year USPI EBITDA at the midpoint. Turning to our cash flow for ’25, we expect cash flow from operations in the range of $2,500,000,000 to $2,850,000,000 capital expenditures in the range of $700,000,000 to $800,000,000 resulting in free cash flows in the range of $1,800,000,000 to $2,050,000,000 In addition, we’re also assuming distributions to NCI in the range of $750,000,000 to $800,000,000 which would result in free cash flow after NCI in the range of $1,050,000,000 to $1,250,000,000 And finally, as a reminder, our capital deployment priorities have not changed. First, we will continue to prioritize capital investments to grow USPI through M and A.
Second, we expect to continue to invest in key hospital growth opportunities, including our focus on higher acuity service offerings. Third, we will evaluate opportunities to retire and or refinance debt. And finally, we’ll have a balanced approach to share repurchases depending on market conditions and other investment opportunities. Given our attractive free cash flow profile and current valuations, we plan to be active repurchasers of shares in 2025. In conclusion, we had an outstanding year in 2024 with effective operational execution, robust growth and a transformed portfolio of businesses.
We’re confident in our ability to deliver on our outlook for ’25 and continue to drive value for patients, physician partners and shareholders. And with that, we’re ready to begin our Q and A. Operator?
Conference Operator: Thank you. At this time, we’ll be conducting a question and answer session. Our first question comes from Pedro Chikharin with Deutsche Bank (ETR:DBKGn). Please proceed with your question.
Pedro Chikharin, Analyst, Deutsche Bank: Good morning, guys. Thanks for taking my question. So looking at tenants over the last few years, the biggest change has been the cash flows in your deleveraging. Your cash flow guidance for this year is up 90% year over year with nearly $1,000,000,000 more cash flow from operations. So looking at your cash flow guidance for this year after NCI, it’s about $1,150,000,000 at the midpoint.
If we pull out $250,000,000 for M and A, it’s about $900,000,000 left to deploy with the leverage at sort of 3.2 times EBITDA less NCI. Can you refresh us on what your ideal target leverage ratios are? And should we be modeling the rest of that going to share repo at this point? Thank you.
Sam Satoria, Chairman and Chief Executive Officer, Tennant Healthcare: Hey, Peter, it’s Sam. First of all, I appreciate reiterating the improvements that we’ve made in generating free cash flow from this business from operations. It’s obviously been a very important part of our goal over the last few years and getting to this point probably earlier than we thought. We’re very comfortable with the leverage that we operate at today. And importantly, it gives us we look at it and say it gives us significant strategic flexibility with respect to the business, both in terms of activity that we may pursue in growing and scaling USPI, as I noted in my comments, but also from the perspective, especially as I said at these valuation multiples, in terms of share repurchase and both Sun and I noted that we would plan to be active repurchasers of our shares at these multiples makes complete sense.
We don’t have debt coming due for a couple of years, right? I mean, so we’re not in any situation of urgency there regardless. And I think the return on share repurchase at this point would be higher anyway. So our thinking is relatively clear about that in the coming years. Obviously, we need to continue executing operationally with the track record that we’ve built to generate that free cash flow.
But as we’ve talked about in the last couple of years, we’ve really hardwired our approach there. The last thing I would point out in addition to what I said about USPI in my comments, we don’t USPI does not have a tremendous amount of Medicaid exposure. So when you think about utilization of our cash flows and regulatory risks that may be out there, I mean, the reality is half our EBITDA is generated in a segment that isn’t really facing risk from any scenario out there related to Medicaid programs. And that’s very helpful. It’s very different than it might have looked five or six years ago.
So we feel confident about the valuation opportunities for the company.
Conference Operator: Our next question comes from Jamie Persse with Goldman Sachs. Please proceed with your question.
Jamie Persse, Analyst, Goldman Sachs: Hey, good morning. Thanks for taking the question. Can you maybe spend a minute on just the volume environment that you’re seeing today? Obviously, 2023 and 2024 were pretty strong years, some of that just recovery and normalization post the pandemic. Where do you think we’re at from a volume perspective today?
And
Sam Satoria, Chairman and Chief Executive Officer, Tennant Healthcare: how
Jamie Persse, Analyst, Goldman Sachs: do you expect volumes to progress throughout the course of the year?
Sam Satoria, Chairman and Chief Executive Officer, Tennant Healthcare: Yes. Thanks, Jimmy. I mean, the simplest statement I would make right now is that we’ve anticipated the volume environment continuing to be strong coming into 2025. I mean, that’s the simplest summary statement I would make. We don’t there aren’t obvious trends from December 31 to January 1 that appear to have changed.
I mean, the coverage environment looks good. The employment environment looks good. Demographics, both in terms of areas where at least our portfolio is now positioned relative to where it was, has attractive demographics. And as we’ve noted, we’ve had opportunity to expand capacity and take on that capacity without excessive cost to do so, and we’re doing it in a deliberate way. So we I mean, our guidance reflects that.
We feel pretty good about going into 2020, ’20 ’20 ’5.
Jamie Persse, Analyst, Goldman Sachs: Okay. Thank you.
Conference Operator: Our next question comes from Brian Tanalworth with Jefferies. Please proceed with your question.
Brian Tanalworth, Analyst, Jefferies: Hey, good morning guys and congrats on
Sun Park, Executive Vice President and Chief Financial Officer, Tennant Healthcare: the quarter. Maybe, Sam, as
Brian Tanalworth, Analyst, Jefferies: I think about your comments on Medicaid and USPI, just curious how you’re thinking about the risk overall for the company from all the political headlines that are out there and what the republics are trying to do with changes to health care policy and what you’re doing to prepare for that, just for that potential change, whether it’s Medicaid or health insurance exchanges across both business lines? Thanks.
Sam Satoria, Chairman and Chief Executive Officer, Tennant Healthcare: Yes. Thanks, Brian. A few things. So I mean, first of all, the fundamental underpinnings of success in an environment with any kind of uncertainty, in our view is operating discipline in what we do, right? And the other important underpinning is having a clear understanding of the economics of our business internally, meaning we understand clearly our service lines, our markets, etcetera, that may have greater dependency or less dependency upon certain types of supplemental payments, where, for example, the strength in the exchanges has contributed to earnings, etcetera.
So the combination of the operating discipline and the insights about the business probably give us an opportunity to manage and pivot as needed depending on what happens. You’re right, the segments are different. I mean, I we’ve taken the opportunity over the past few years to create resiliency in USPI by making sure that the ambulatory surgery centers as a part of USPI are on freestanding rates. The Medicaid exposure is de minimis in that business and that’s very helpful from that perspective. And the exchange business there has had less impact than it’s had on the acute care segment in terms of the exchange growth from that perspective.
So from a USPI perspective, look, this is all about an important tailwind of moving things into a lower cost setting in an expensive portion of the healthcare industry, which is surgical care, right, and doing so in a way where we’re constantly increasing the acuity of the work at USPI because it creates more value for the purchaser. On the acute care hospital side, I think it’s important to continue to search for efficiencies that allow us to generate margins. We always talk about the concept of Medicare profitability, right? Can you generate margins on Medicare reimbursement in order to have a metric out there for efficiency goals that you would create because it’s important to be able to operate in that type of environment. Specifically on the acute care side, the number one adaptive action today is helping the regulators understand the importance that these programs provide for basic access for people that wouldn’t otherwise have access to care.
And that’s really important because if that shapes or is a factor in shaping policy, I think that what comes out of that policy will likely be manageable for us and something that we can get behind. I’m not sure that right now taking a bunch of actions to restructure the business is the right thing to do. I think there’s a very strong case to be made that many of these things are really critical to providing access. And it happens to be that that access is also being provided in states with voters that really matter to this administration and that’s an important supporting factor as well.
Conference Operator: Our next question comes from Andrew Mak with Barclays (LON:BARC). Please proceed with your question.
Andrew Mak, Analyst, Barclays: Hi, good morning. When I look at the ASC case mix from ’23 to ’24, it doesn’t look like there are significant mix changes. We actually see MSK down one percentage point and ophthalmology up one percentage point, but you’re increasing acuity significantly to the point where you’re seeing high single digit same store revenue growth without meaningful case growth. So can you speak to the types of cases driving acuity higher because it’s not obvious from the case mix disclosures? Thanks.
Sam Satoria, Chairman and Chief Executive Officer, Tennant Healthcare: Yes, no problem. I mean, just to clarify, the orthopedics line item has a lot of things in there. That’s why we call out the highest security work in joint cases, for example, which is where you have the hips, knees, obviously, the shoulder expansion, that’s where the acuity is actually growing. I mean, remember, when you look at certain low acuity procedures that we may do in ASCs, the revenue I mean, we’re doing exactly what we wanted with the business, which is we’re growing the acuity, we’re growing the net revenue per case, we are reducing exposure to high volume, low revenue cases, in some cases, things that could also be done in offices that further strengthen the resiliency and value of what USPI is building. So that orthopedics line item has a lot of things in there from high acuity to low acuity cases.
And it’s the reason we call out the really high acuity work because it’s a fundamental driver of the net revenue per case strength which you’re seeing.
Sun Park, Executive Vice President and Chief Financial Officer, Tennant Healthcare: Great. Thanks for the color.
John Ransom, Analyst, Raymond (NSE:RYMD) James: Sure.
Conference Operator: Our next question comes from Justin Lake with Wolfe Research. Please proceed with your question.
Sam Satoria, Chairman and Chief Executive Officer, Tennant Healthcare0: Thanks. Good morning. Couple of things just numbers wise. Maybe you could tell us you’ve mentioned Tennessee as a tailwind at $35,000,000 You mentioned, for instance, Michigan is not going to you’re going to have a little bit of a one time endwind there. But when you think about ex those issues kind of core DPP dollars year over year, can you tell us what’s assumed in the guidance?
And then same for exchanges, like what kind of exchange growth do you kind of expect in your markets, exchange volume growth within that guidance? Thanks.
Sun Park, Executive Vice President and Chief Financial Officer, Tennant Healthcare: Hey, Justin, it’s Sun, and thanks for the question. On your question about supplemental payments, yes, I think you called out the kind of the one timers that we’ve referenced. The other point in fiscal twenty twenty four is we still had a little bit of value from hospitals that were then that divested during the course of the year, but that’s mostly in Q1. So there are a couple of those moving factors. But in fiscal ’twenty four, we generated about $1,160,000,000 of net Medicaid supplemental payments.
Going into ’twenty five, our guidance assumes something pretty consistent with that. You mentioned the Tennessee one time, but excluding that, we’re pretty consistent year over year. On your question about exchange, as we’ve said multiple times, total emissions and revenues from exchange population was a strong growth driver in 2024. We expect that to continue per Saum’s earlier comments around the overall volume environment. The enrollment, the renewal cycle seems to have been positive.
We’ll see how much of that turns into actual admissions. But we certainly won’t see the 40%, fifty % growth that we saw in 2024, but we still continue to see a strong environment. Just as an example, we’re our strategy long term strategy has always to be in broad networks from a contracting standpoint as an example. So we see good things for ’25. Thanks for the question.
Conference Operator: Our next question comes from Benjamin Rossi with JPMorgan Chase (NYSE:JPM). Please proceed with your question.
Sam Satoria, Chairman and Chief Executive Officer, Tennant Healthcare1: Hey, good morning. Thanks for the question here. So, just across supplies, we’re
Conference Operator: seeing some
Sam Satoria, Chairman and Chief Executive Officer, Tennant Healthcare1: pressure here as a percentage of revenue with that category increasing about 100 bps year over year to 18.3. How would you characterize your current supply dynamics exiting the quarter? Is there anything discrete occurring within there? Is this largely a byproduct of your push to higher Just kind of curious where you’re seeing that number settling out in the steady state during 2025? Thanks.
Andrew Mak, Analyst, Barclays: Yes. Hey, Ben. Yes, I
Sun Park, Executive Vice President and Chief Financial Officer, Tennant Healthcare: think it’s what you said on the latter piece. It is just kind of part and parcel with our acuity strategy. So the supplies will go up as a percentage a little bit in Q4. But over the year, we’ve been pretty well balanced and we expect it to be again balanced in 2025. Got it.
Thanks. Thank you.
Conference Operator: Our next question comes from Joanna Gajic with Bank of America (NYSE:BAC). Please proceed with your question.
Sam Satoria, Chairman and Chief Executive Officer, Tennant Healthcare2: Hi, good morning. Thanks so much for taking that question. So on the guidance element, Ambulatory same store revenue 3% to 6%, right? That seems to be sort of more like a normalized growth, right? Because clearly you grew very nicely in 24%, almost 8%.
So is it just conservatism? Could you maybe also break down volumes versus pricing that’s included in that range? Thank you.
Sam Satoria, Chairman and Chief Executive Officer, Tennant Healthcare: Yes. Hey, it’s Sam. Look, a couple of things there. First of all, long term, as we’ve learned with USPI, and I think we’ve shared this data before, we’ve looked at ten years’ worth of USPI’s performance and same store growth rates of around 4% to 6% is what we guide to. Now history suggests over that ten year period, we’ve performed at the upper end of that range, 6%.
That has looked better, strengthened over the last five, six years actually over that average period, okay? So you point out this year almost or this year, past year twenty four, seven point eight percent. The prior year was 9.2% growth rate. So we’re running very hot from that perspective in terms of long term averages with respect to USPI. So our guide just comes brings us right back to what our long term growth rate is.
In terms of the year to year, as you’ve seen, it can be lumpy, right? ’23, huge volume growth ’24, more growth in acuity and intensity. And part of what we’re signaling for 2025 is it’s definitely our plan to continue this shift to higher acuity procedures. I started to point out some of the factors driving that in terms of the revenue intensity of some of these cases, how efficiently we’re able to do them in our operating rooms now and generate margin, how we are scaling those programs into more centers. We now have robots in almost 150 of our programs around the country.
This is the direction in which we’re taking the organization. And so, yes, the guidance reflects kind of our long term average, but we’ve obviously been running quite a bit above that.
Conference Operator: Our next question comes from A. J. Rice with UBS. Please proceed with your question.
Sam Satoria, Chairman and Chief Executive Officer, Tennant Healthcare3: Hi, everybody. Thought I would ask maybe on the where you’re at with managed care contracting. I know we’ve been in a period where you’ve been getting a little bit toward the high end of historical rate updates to pay for some of the labor challenges in the last few years? Is 25 a year in which you’ll still see that type of dynamic, maybe where you’re at in terms of signing up contracts? And then also on the managed care side, any update on thoughts about denial activity, prior authorization challenges, other term changes that you’re dealing with?
Sam Satoria, Chairman and Chief Executive Officer, Tennant Healthcare: Yes. Why don’t we take those in reverse? The I mean, I would say that the environment is no different than it has been. I mean, there’s a constant back and forth of administrative costs that goes into adjudicating claims that probably is unnecessary, but obviously both sides have a point of view on that. What I would say more importantly than anything else from our perspective is the work that Conifer does in driving initial disputes to a very, very attractive low rate of denials is critical.
And our skill set in doing that in both working collaboratively with the payers and adversely where needed on the basis of solid documentation, appropriate coding, compliant coding and efficient revenue cycle operations has made a big difference. We’re seeing a gap in what we generate in terms of lower denial rates than the industry from what we are seeing with respect to initial dispute rates. And that’s good because that means we’re doing things right in generating the appropriate cash flow from the work we’re doing. Sun, maybe you want to comment on the managed care side.
Sun Park, Executive Vice President and Chief Financial Officer, Tennant Healthcare: Thanks, Sam. A. J, for your first part of the question, as we’ve said historically, we are continuing to see commercial rates increases in the 3% to 5% range and some of the contracts have been at or slightly above the high end of that range as respect to the inflationary pressures that you’ve mentioned. So I think the overall situation there is pretty consistent. And then in terms of contracting, going to 25%, we’re about we’re over 90% contracted for 25% and probably about over 50% contracted for 26% as well.
So we have great visibility into 25% and beyond. Thanks for your question.
Conference Operator: Our next question comes from Stephen Baxter (NYSE:BAX) with Wells Fargo (NYSE:WFC). Please proceed with your question.
Brian Tanalworth, Analyst, Jefferies: Hi, thanks. Wanted to come back to the same store hospital volume guidance for 2025. I appreciate you’re still expecting exchange growth inside of that number to some degree. Would also love to hear any quantification you can offer about how much hospital capacity you’ll have online in 2025 compared to 2024? Trying to break out that 2% to 3% and maybe think about maybe what’s the market level growth inside of that compared to how much of it’s coming from capacity?
Thank you.
Sam Satoria, Chairman and Chief Executive Officer, Tennant Healthcare: Yes. Hey, Steven, it’s obviously both. I mean, the majority of that is the market level demand that we’re seeing versus the selective markets in which there’s still capacity that we’re bringing online. But it is a contributor, which is why I called it out before. We haven’t quantified what that looks like between the two numbers, but it is both and the majority of it is market based demand across the board.
Some of this is also related to the service line choices we make, of course, which have higher growth rates. The things that we’re doing that are taking care of people with multiple chronic illnesses that continue to grow in prevalence are continuing to create more demand than perhaps certain types of lower acuity work, which may be coming out of hospitals in our environment. And so that’s really how we think about it in terms of the growth rates.
Brian Tanalworth, Analyst, Jefferies: Yes,
Sam Satoria, Chairman and Chief Executive Officer, Tennant Healthcare: look, it’s been a very busy year in the acute care environment. And as I said, I think the most important thing we’re taking into the year from a mindset perspective is we’re not seeing changes in the demand patterns. That was a comment to Jamie’s question earlier. We’re not seeing changes in the demand pattern right now. And so I mean, I’m not going to go forecasting what we may see in the later part of the year, but we’re not seeing that right now.
Conference Operator: Our next question comes from Michael with Baird. Please proceed with your question.
Andrew Mak, Analyst, Barclays: Hi, thank you. Just a quick clarification first and then my real one and apologies if I missed it, but your USPI 3% to 6% rev growth guide, what’s the volume versus pricing split on that? And then my real question, I’m sorry to add one more question on policy. And I understand USPI is minimal Medicaid exposure, but for your hospital and maybe taking a different approach, just given all the news flow, NIH cuts, Doge’s potential focus on Medicaid, administrative costs. If Doge were to implement those cuts, it might not be overly impactful, but still perhaps a couple percent of overall Medicaid spend.
So I’m curious to hear your view. If that were to happen, how do you think states might react? What’s your view on the likelihood that states might potentially slow that Medicaid cut down to provider rates and impact tenant and hospitals more broadly? Thank you.
Sam Satoria, Chairman and Chief Executive Officer, Tennant Healthcare: Yes. A couple of different things. So let’s just start with the business side of it first. With respect to USPI, as I indicated, there’s no long term deviation from our approach of thinking about half and half roughly managed care and volume at USPI. But because it’s lumpy and it’s proven to be lumpy, we’re not guiding specifically for the year with respect to that.
And you can understand that. I mean, we’re successfully now two years in a row executing our strategy of increasing lower volume, high acuity cases. And in fact, as you can tell from our quarterly beats consistently, we’re exceeding what we expect from the standpoint of what we can do in same store revenue growth in that environment. And so we’re pleased by that, that we can do that. We obviously had a little bit of fits and starts around that a few years ago in terms of how we were executing it.
But we got it right and it’s working and I’m really pleased with that. So the long term algorithm is the same, but from a short term standpoint, we’re giving you the revenue guidance with obviously the track record of it being stronger. I don’t on the policy side, I think to be clear, like we don’t have even in our academic medical center enterprises and affiliations, we don’t have significant NIH or NSF indirect grant cost exposure in our business. So in particular, as you can imagine, when we saw that, we thought about that in our environment and where we had R01 grants and other things within our environment. But we don’t have that significantly in our environment.
I think the broader question of Medicaid policy and other things is an important one. But look, the focus on that is articulated and you can’t tell what’s going to happen, but the focus that’s articulated on reducing fraud and abuse, including in some of the public comments made yesterday all the way in the Oval Office. I think one thing that people may find is that Medicaid redeterminations over the last couple of years have probably done a lot to reduce the number of people eligible or not eligible who happen to be on Medicaid. And so I’m again, no way to predict for sure, but I’m somewhat comforted by the fact that some of that work has already been done through this redetermination process. So we’ll see where this goes and what remains to be seen.
Finally, as to speculation, speculating on what the states’ responses may be, I think the states are going to be important allies across the board in advocating for, the dollars that come through these Medicaid partnerships with the federal government. Because again, I go back to this is the only way to create access for the people that need it that are on Medicaid. This is not some program that’s generating incredible windfalls for health systems on that basis. The unit reimbursement is still below the cost of that care. And so I think that that’s going to be an important balancing factor.
The states will play an important role in this.
Conference Operator: Our next question comes from Ann Hynes with Mizuho. Please proceed with your question.
Ann Hynes, Analyst, Mizuho: Hi, good morning. So I know there’s some big Surgery Center assets out there in the market. Can you remind us given your delivered balance sheet, what your appetite is versus larger scale M and A in the Surgery Center business?
Sam Satoria, Chairman and Chief Executive Officer, Tennant Healthcare: Hey, Anne, it’s Sam. Obviously, I’m not going to comment on any kind of M and A opportunities. We’re very aware of everything that’s available in the market. We’ve proven our ability over the last few years to deploy M and A capital both on a single asset basis and large multicenter asset acquisitions. I would tell you that the first year post our acquisition early last year of the portfolio that we took on went better than we thought it would.
So that’s good news. And as I said early on in my comments, our balance sheet provides us plenty of flexibility to approach things. But look, we’re disciplined. We believe in growth businesses. We believe in areas in which we can add value.
And we have a lot of flexibility given our cash flow generation and valuation multiple to deploy cash for the benefit of shareholders in multiple different avenues at this point.
Conference Operator: Our next question comes from Whit Mayo with Leerink Partners. Please proceed with your question.
Pedro Chikharin, Analyst, Deutsche Bank: Hey, good morning. Just to stick on USPI for a second. Are there any new health system partners that we may not be aware of in the last year? I know you’ve been selective and disciplined with the financial strength of the partners that you want to work with, but I’m just not sure I’ve had an update or heard an update on anything new or any expanded relationships with any health systems in some time? And maybe just a broader comment on the de novo activity, the 10 to 12 this year, any of those with new partners or those all existing partners?
Thanks.
Sam Satoria, Chairman and Chief Executive Officer, Tennant Healthcare: Yes. Hey, Wade, it’s Sam. Now we haven’t provided any updates on health system partners and other things. And remember, I mean, our platform is such that we work just as effectively with partners as we do without partners because of our ability to generate contract synergies, managed care, supply chain, everything, right, in our management capacity for these assets. So we’re growing the portfolio in both with both vectors, and I don’t think that’s going to change.
I mean, I think the expansion of de novo assets can occur in many different ways. Some are in existing markets, some are in new markets, some are with MSOs that are expanding their physician side footprint. And as I’ve said in the past, have realized that there isn’t a better operator of ASCs to generate margin from those investments for those doctors than USPI. So that’s another vector of growth that is helping to create de novo activities. It’s a multi pronged growth strategy, and I don’t think that’s really going to change looking forward.
Conference Operator: Our next question comes from John Ransom with Raymond James. Please proceed with your question.
John Ransom, Analyst, Raymond James: Hey, good morning. Saum, I predict you’ll hate this question, but bear with me. So we’ve heard from a few folks that the fourth quarter seasonal uptick is not quite what it used to be because just the fact that deductibles have gotten so high, particularly in commercial plans. Do you think there’s any evidence of that?
Sam Satoria, Chairman and Chief Executive Officer, Tennant Healthcare: John, are you referring just care delivery overall or USPI specifically ambulatory surgery?
John Ransom, Analyst, Raymond James: I meant electives. So electives either in the hospital or in the USPI.
Sam Satoria, Chairman and Chief Executive Officer, Tennant Healthcare: Yes, elective work. Well, it’s I mean, again, I’m not sure that I’m going to be able to give you a statistically significant answer, but I would say that the seasonality in Q4 and especially as that ramps into Q1 on elective surgery is it has tempered a bit. I mean, Q4 is still a more productive quarter. Our asset utilization in our USPI segment does go up still in Q4, but it has tempered a bit overall. And also and how much of it is the deductibles versus somewhat the impact of if you look at our Q4, the impact of just some of these weather events were relevant.
And so how much of it was a seasonality shift versus some of the weather events that we I don’t know that we’ve really calculated that. But it is I mean, you’re picking up on something that we’ve sort of said, intuitively, it feels a little bit different, but the general pattern hasn’t changed.
John Ransom, Analyst, Raymond James: And so just my follow-up and thanks for that answer. If we look at ’twenty three and ’twenty four, utilization was up for in ’twenty three, I’d say, electives and ’twenty four, there was a bunch of other stuff going on like two midnight rule and cancer cases and what have you. Do you think again, probably you can’t answer this question, but it seems to us like ’twenty ’5, we’re kind of back to more kind of a normalized year where maybe we’ve cleared out all the COVID backlog and we’re kind of clear all of these kind of wonky events in ’twenty three and ’twenty four. Is that kind of your and is that what’s implied in your guidance? Is that that’s kind of where we are?
Sam Satoria, Chairman and Chief Executive Officer, Tennant Healthcare: I mean, that is kind of I mean, at some point, we have to get back to an environment where we’re not explaining everything either on the basis of COVID or post COVID or whatever the case may be, no one ever gets that entirely right. But I do think that, that is a little bit of what the guidance implies. And as I said, I think that’s a fair way to plan for the year. And yet at the same time, I don’t see shifts necessarily in the strength the strong demand environment that we saw in 2024 yet in particular. So we’ll see how that plays out.
John Ransom, Analyst, Raymond James: Thank you.
Sam Satoria, Chairman and Chief Executive Officer, Tennant Healthcare: Thanks.
Conference Operator: Our next question comes from Josh Raskin with Nephron Research. Please proceed with your question. Thanks. I’m going to stick on the USBI topic. So can you speak maybe to the broader competitive landscape for ASC transactions?
Are you seeing more competition? And if you could differentiate between larger sets of assets or even one offs or even competitors developing de novos in your markets? And then in your prepared remarks, Saum, you mentioned the de novo growth. Is that indicative of more what we’ll call sort of organic center expansions as opposed to acquired centers?
Sam Satoria, Chairman and Chief Executive Officer, Tennant Healthcare: Well, let me go in reverse. Look, we think de novo development activity is really critical and we’ve been focused on that and scaling that up. I mean, again, part of our thinking here, Josh, is that consistent with our move into more high acuity ambulatory surgical work, de novos also represent a significant value shift in markets, right? Because usually what you’re doing is you’re building from the ground up, you’re moving things into a lower cost setting. It’s value for the consumers and payers in the markets to be focused on de novos in addition to everything else that we may be doing to grow the portfolio and expand the high acuity services.
So that it’s part of our value strategy there and maybe that’s why you’re seeing more of it from the de novo side. In terms of the competitive landscape, no, I don’t think the competitive landscape has changed. I mean, the easiest way to assess the competitive landscape is to just count the center counts across different organizations and some are scaling better than others. And that probably more than anything reflects competitive the output of whatever competitive intensity exists. We’ve been pretty pleased with our ability to scale, win competitive situations and processes where we want them and maintain high quality, high profit margin centers.
And we always assess that pipeline every year. The pipeline still looks good for doing that.
Conference Operator: That’s helpful. Is it fair to assume that the de novo long term returns on capital are higher?
Sam Satoria, Chairman and Chief Executive Officer, Tennant Healthcare: Yes, of course. Yes, because again, it’s not like building an acute care facility, right? The building costs are low. It’s a shorter time frame once the partnership is syndicated. There’s work upfront in syndicating the partnership that takes time, but that’s not a capital intensive activity.
Look, I think at the start of this, Peto pointed out one of the big changes in the organization around the generation of free cash flow. We also focus on measuring and following our overall return on invested capital within the organization. And obviously, the more we shift into this ambulatory segment, the more that gets better. And obviously, the more we do de novos, we see that, that gets better in
Ann Hynes, Analyst, Mizuho: terms
Sam Satoria, Chairman and Chief Executive Officer, Tennant Healthcare: of what we’re doing in the business when we’re deploying our cash. So yes, you’re absolutely picking up on what we’re doing for the right reasons.
Conference Operator: Our next question comes from Matthew Gillmor with KeyBanc Capital Markets. Please proceed with your question.
Sam Satoria, Chairman and Chief Executive Officer, Tennant Healthcare0: Hey, thanks. I wanted to follow-up on the cost management and efficiency comments. The company has clearly made a lot of progress the last few years and you noted the SWB and contract labor metrics. As you look ahead, are there any areas of particular focus that are going to continue to drive efficiency in 2025 and beyond that you’d highlight for us?
Sam Satoria, Chairman and Chief Executive Officer, Tennant Healthcare: Sure. I mean, I think that the cost management agenda doesn’t change in terms of managing labor, managing supplies, managing purchase services, active vendor consolidation activities, scaling our service lines in which we’ve got a cost structure that we’re comfortable with. Obviously, just that scale creates opportunity. I’ve said in the Acute Care segment, I’ve said all along, we’re really pleased with the improvements that we’ve made in so many of the metrics from the standpoint of cost, labor, overhead, supplies, purchase services, relative to our peer set in the industry. Obviously, we always continue to note that an area that we can improve is our asset utilization.
And that’s obviously in comparison to what we look at as kind of the gold standard out there. So that’s really an area that we’re continuing to work on as we expand capacity and build volumes into some of the facilities that we took capacity offline during the pandemic from an efficiency standpoint. Our global business center has contributed significantly to our cost savings. If you think about the last four, five years, the journey we’ve been on, of course, there’s obvious unit cost savings that you see on an immediate basis, but there’s a lot of cash flow that goes into actually restructuring and building and scaling that enterprise. And what might have started with kind of commodity work in certain areas of finance or accounts receivable has expanded to ten, twelve different service lines that we are now running effectively in the global business center, clinical areas, clinical analytics, physician credentialing, a variety of things.
And that’s an important part of our efficiency agenda as we look forward as well. And it’s now that it’s obviously well past breakeven cash flow, those savings materially contribute to what we’re doing.
Conference Operator: Our next question is from Ben Hendricks with RBC Capital Markets. Please proceed with your question.
Brian Tanalworth, Analyst, Jefferies: Hi. This is Mike Murray on for Ben. Thanks for taking my question. So ASC total joint procedures grew nicely in 2024. I wanted to hear your expectations for growth in 2025 and beyond.
And then cardiology procedures have been the latest slated to drive material growth in ASCs. Can you discuss any early progress there? And when do you see these procedures really accelerating? Thanks.
Sam Satoria, Chairman and Chief Executive Officer, Tennant Healthcare: Yes. Hey, it’s Sam. We obviously, we anticipate continuing to focus on our Orthopaedics line of business going forward. We’re not going to guide service line level volumes from that perspective. But we still think, obviously, there’s a tailwind in ambulatory surgical growth from an Orthopaedic standpoint.
And that’s both the stuff we’re doing today and expansion of the procedure set that could be done safely in an ASC. Same with cardiac. I mean, as I’ve said all along, the opportunity in a wide variety of cardiovascular procedures is there. I’ve always been clear that I think that that opportunity will proceed more slowly than people anticipate, because of important patient safety considerations and payer mix considerations. And also the CapEx required to build a cardiac center is very different than building other types of ASCs given the equipment that you have to have in there.
So the upfront investment for the physician partners and other things is much higher with potentially lower margin assets. And so from economic reasons and patient safety reasons, I think this market will evolve, but I think it will evolve slower than people like to think. And we’ll obviously be participants in that as we are today, but we’re also we’re not going to try to rush it and sacrifice patient safety and quality in that regard.
Brian Tanalworth, Analyst, Jefferies: That’s helpful. Thank you.
Conference Operator: This concludes today’s conference. You may disconnect your lines at this time and we thank you for your participation.
This article was generated with the support of AI and reviewed by an editor. For more information see our T&C.