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Community Health Systems, inc (NYSE:CYH)
Q3 2021 Earnings Call
Oct 28, 2021, 11:00 a.m. ET

Contents:

  • Prepared Remarks
  • Questions and Answers
  • Call Participants

Prepared Remarks:

Operator

Good day, and thank you for standing by. Welcome to Community Health Systems Third Quarter 2021 Earnings Call. Please be advised that today's conference is being recorded. I would now like to hand the conference over to your speaker for today, Mr. Ross Comeaux, Vice President of Investors Relations.

Ross W. Comeaux -- Vice President of Investor Relations

Thank you, Jay. Good morning, and welcome to Community Health Systems' Third Quarter 2021 Conference Call. Joining me on today's call are Tim Hingtgen, Chief Executive Officer; Dr. Lynn Simon, President of Clinical Operations and Chief Medical Officer; and Kevin Hammons, President and Chief Financial Officer. Before I turn the call over to Tim, I would like to remind everyone that this conference call may contain certain forward looking statements, including all statements that do not relate solely to historical or current facts. These forward looking statements are subject to a number of known and unknown risks, which are described in headings such as Risk Factors in our annual report on Form 10-K and other reports filed with or furnished to the Securities and Exchange Commission. As a consequence, actual results may differ significantly from those expressed in any forward looking statements in today's discussion. We do not intend to update any of these forward looking statements. Yesterday afternoon, we issued a press release with our financial statements and definitions and calculations of adjusted EBITDA and adjusted EPS. For those of you listening to the live broadcast of this conference call, a supplemental slide presentation has been posted to our website. We will refer to those slides during this earnings call. All calculations we will discuss also exclude loss or gain from early extinguishment of debt impairment expense as well as gains or losses on the sale of businesses; expenses from government and other legal settlements and related costs, expenses from settlement and legal expenses related to cases covered by the CVR expenses related to employee termination benefits and other restructuring charges, change in tax valuation allowance and gain on sale of investments and unconsolidated affiliates. With that said, I'd like to turn the call over to Tim Hingtgen, Chief Executive Officer.

Tim L. Hingtgen -- Chief Executive Officer and Director

Thank you, Rob. Good morning, everyone, and welcome to our third quarter conference call. We are very pleased with our third quarter operational and financial performance, especially as our healthcare teams provided care for a large number of patients with COVID-19. Despite this challenging environment, we continue to advance key growth strategies and other important operational improvements. During the third quarter, the Delta variance spread through many of our markets across the Sun Belt space. As a result, we provided care for approximately 15,000 inpatient COVID admissions or 13% of our total admissions, which was our highest quarterly case count to date. This compared to more than 3,000 inpatient COVID cases during the second quarter and 9,500 during the first quarter. And it is also worth noting that non-COVID healthcare demand was higher in the third quarter than in our prior quarters with elevated COVID-19 cases. Since the onset of the pandemic, the importance of our healthcare team and the critical role they play in the communities we serve has certainly been reinforced. I am impressed with their professionalism and compassion and remain grateful for their commitment to providing safe, high quality patient care. Looking at the third quarter, we produced strong results despite the COVID surge. On a same store and year over year basis, net revenue increased 7.1%. Same store admissions increased 2.8% and adjusted admissions were up 4.7%. Surgeries increased 1.5%, while ER visits were up 24.2%. As a reminder, during the third quarter of 2020, we drove solid volume recovery as industry volumes were returning. So we were pleased with this year over year volume performance. Looking at our third quarter volumes compared to the pre-pandemic third quarter of 2019, same store admissions decreased 3%, while surgeries declined 4%. ER visits further improved and were up 1% versus 2019 due in large part to our freestanding ED expansion strategy as well as elevated levels of COVID visits and testing.

Despite the COVID surge in the third quarter being our largest to date, non-COVID demand was higher than the last significant surge in the first quarter of this year. As a result, we delivered stronger volumes across all key metrics compared to the first quarter. That said, deferred care and related procedures have been impacted throughout the pandemic, and we expect healthcare demand to return over the next several quarters. And our recent investment, which I will cover in more detail shortly, will help meet growing demand for healthcare services in the months and years ahead, and drive market share gains across our portfolio. Moving now to EBITDA during the third quarter. On a consolidated basis, adjusted EBITDA was $482 million. Excluding pandemic relief funds, adjusted EBITDA was $463 million, which was up 7% year over year, with an adjusted EBITDA margin of 14.8%. Compared to the third quarter of 2019 and excluding release pandemic relief fund, adjusted EBITDA increased 19%, and our adjusted EBITDA margin was up 280 basis points despite operating 19 fewer hospitals, which further validates our underlying confidence in the renewed core portfolio.

In terms of expense management, for more than 1.5 years now, the pandemic has created a continuously changing operating environment, requiring flexibility on a daily basis. This was certainly the case again during this quarter. Our hospital leadership teams and providers have adeptly managed the ebbs and flows, utilizing best practices, leveraging organizational resources and operating with agility all while prioritizing safety for their patients and care teams. They continue to effectively manage their resources and control expenses. Similar to prior waves of COVID, we experienced increased costs related to staffing, pharmaceuticals and other supplies, such as PPE and COVID testing. And while the entire country is ready for the impacts of COVID-19 to subside, we remain confident in our ability to manage the dual-track operation strategy for as long as the pandemic continues. Our portfolio is strong, and it is situated across parts of the country with attractive population trends and favorable economic conditions, which provide a solid foundation for growth over the next several years. To broadly advance these growth opportunities, we have previously highlighted investments in incremental bed capacity new outpatient access points, higher acuity service lines, physician recruitment, our transfer center service, Telehealth technologies and in care coordination and patient experience. These investments are working. They have greatly improved our competitive position and are creating opportunities for incremental market share gains into the future. Now I would like to share with you some of our recent growth oriented investments. They include the JV opportunities, we announced last quarter with partnerships across rehab, long term acute care and behavioral health, the opening of new ASCs in the Knoxville, Tennessee and Tucson, Arizona markets. The recent completion of an OB and neonatal intensive care expansion at Grandview Medical Center in Birmingham, Alabama, where we have now added more than 70 beds over the past three years. The November opening of a new hospital in Downtown Fort Wayne, as part of Lutheran Health Network, the upcoming opening of our 17th freestanding ED near Bentonville, Arkansas, which is part of our Northwest Arkansas network, and a de novo hospital campus, the fourth in Tucson, Arizona, which is scheduled to open in early 2022. We are also excited about the recently announced expansion of the physician's regional healthcare system in Naples, Florida.

This includes the construction of 100 new beds at our two existing hospital campuses in that market and the early 2022 addition of a third hospital campus in North Naples, which will specialize primarily in orthopedic surgery and rehabilitation. Beyond these projects, we have a growing pipeline of both inpatient and outpatient investment opportunities, which we expect to further develop and strengthen our core markets even more. We have been pleased with our progress this year, and in our overall execution in the midst of a challenging operating environment. Due to our strong performance, we are raising our adjusted EBITDA guidance again this quarter. And looking forward, we remain extremely optimistic about our portfolio and markets as well as the opportunities ahead of us to drive long term incremental EBITDA and cash flow growth. At this point, I will turn the call over to Kevin for additional details on the quarter and to provide more thoughts on our future outlook. Kevin?

Kevin J. Hammons -- President and Chief Financial Officer

Thank you, Tim, and good morning, everyone. As Tim highlighted, it was another strong quarter for the company. as we delivered solid financial performance and further advanced a number of our strategic initiatives. Through the recent transformation we've undertaken to reposition the company, we introduced strategies to drive net revenue growth and improve efficiency throughout the organization as well as to strengthen our balance sheet. We completed our divestiture program, which allowed for debt paydown and additional focus in our core markets. We made improvements to the capital structure, extending maturities and reducing annual cash interest. And we've made operational improvements, which have improved our margins. We are pleased with all of this recent progress and excited about the opportunities in front of us. Switching back to the third quarter performance. Net operating revenues came in at $3.115 billion on a consolidated basis. On a same store basis, net revenue was up 7.1% from the prior year. This was the net result of a 4.7% increase in adjusted admissions and a 2.3% increase in net revenue per adjusted admission, which faced a difficult comp from the prior year. Excluding nonpatient revenue, which was lower year over year, net patient revenue per adjusted admission was up 3% compared to the prior year. Adjusted EBITDA was $482 million. During the third quarter, we recorded approximately $19 million of pandemic relief funds with no relief funds recognized in the prior year period. Excluding those pandemic relief funds, adjusted EBITDA was $463 million, with an adjusted EBITDA margin of 14.8%. In terms of expenses, supply cost increased in the third quarter, a result of higher pharmaceutical and other costs associated with caring for additional COVID patients. Contract labor expenses increased in the third quarter similar to prior COVID waves during which COVID case counts were elevated. As a reminder, our contract labor expense is recorded in the other operating expense line.

It's worth noting that our strategic margin improvement program has remained on plan during the year. The formalized program continues to drive efficiency across the organization. and the execution helped to offset cost pressure across all three expense lines during the quarter. We expect this plan will drive incremental savings over the next several years. Turning to cash flow. Cash flows provided by operations were $400 million for the first nine months of 2021. This compares to cash flows from operations of $2.1 billion during the first nine months of 2020. The comparison versus the prior year is difficult as the $2.1 billion in cash flow from operations during the first nine months of 2020 included $1.159 billion of accelerated Medicare payments received and $715 million of pandemic relief funds received. Declining net revenue during the first three quarters of 2020 resulted in declining accounts receivable which was, therefore, a benefit to working capital cash flows last year. Conversely, with strong net revenue growth in the current year, we have a net working capital drag as accounts receivables have increased. We expect this net working capital headwind to ease in future quarters. Excluding repaid Medicare payments, cash flows provided by operations were $667 million for the first nine months of 2020. Moving to capex.

For the first nine months of 2021, our capex was $334 million compared to $317 million in the prior period. Our capex was up 5% in the first nine months of this year despite operating fewer hospitals than a year ago. Our core markets have benefited from the rollout of our strategic initiatives, along with high return capital to fuel additional growth. And as Tim mentioned, we have a strong pipeline of opportunities that we expect will drive incremental EBITDA as well as increased cash flow performance going forward. In terms of liquidity, we continue to have no outstanding borrowings and approximately $728 million of borrowing base capacity under the ABL with the ability for that to increase up to $1 billion. Also at the end of the quarter, we had $1.3 billion of cash on the balance sheet. As of September 30, 2021, the company had $814 million of Medicare accelerated payments remaining to be repaid, which were recorded as a current liability on the balance sheet. Rather than repay these remaining Medicare Accelerated payments over the next several quarters through the regularly scheduled recruitment process by CMS, the company has elected to repay the remaining outstanding balance of Medicare accelerated payments to CMS with cash on hand, which it has now completed during the month of October. Moving forward, the company will begin receiving the full amount of cash reimbursement on future Medicare claims. Due to our strong performance during the quarter, we have raised our guidance. The updated full year 2021 guidance for net revenues is now anticipated to be $12.150 billion to $12.350 billion.

And adjusted EBITDA is anticipated to be $1.780 billion to $1.820 billion as we've increased our full year range. As a reminder, our 2021 adjusted EBITDA guidance does not include any previously recorded pandemic relief funds or any pandemic relief funds that may be recorded in the future. Cash flow from operations is anticipated to be $800 million to $900 million, an increase of $75 million at the midpoint. Our cash flow from operations guidance excludes the repayment of Medicare accelerated payments that have occurred throughout the year. capex is now expected to be $450 million to $500 million, and net income per share is anticipated to be $1 to $1.20 based on a weighted average diluted shares outstanding of 129 million to 131 million shares. Lastly, at the beginning of this year, we introduced our medium term financial goals, which included achieving 15% plus adjusted EBITDA margins, delivering positive free cash flow annually and reducing financial leverage below six times. Looking at the past three quarters, we've made significant progress on these goals as we've expanded our EBITDA margin, driven strong positive free cash flow year to date and further reduced our leverage, which is 5.9 times as of September 30. We look forward to delivering additional progress across all these metrics as we move forward. Ross, at this point, I will return the call back to you.

Ross W. Comeaux -- Vice President of Investor Relations

Thank you, Kevin, and thank you, Tim. Jay, at this point, we're ready to open up the call for questions. We'll limit everyone to one question this morning. But as always, you can reach it (615) 465-7000.

Questions and Answers:

Operator

[Operator Instructions] Our first question comes from the line of Brian Tanquilut of Jefferies.

Brian Tanquilut -- Jefferies -- Analyst

Congrats on a good quarter.

Ross W. Comeaux -- Vice President of Investor Relations

Thanks, Brian.

Brian Tanquilut -- Jefferies -- Analyst

So I guess my question is, obviously, everyone is worried about the cost side of things and whether it's labor and supplies and whatnot. But it's clear that you guys managed the cost side well even with increased utilization of temp labor. So as I look at things and the turnaround that you've done over the last few quarters, maybe if you can share with us what exactly are the initiatives that you're doing or that you've set up to implement as it relates to driving revenues and admission trends? And also on the other side, just the cost and margin enhancement moves that you've outlined, what are those things more concretely? And where do we stand in terms of like what innings are we in, in terms of realizing those benefits?

Kevin J. Hammons -- President and Chief Financial Officer

Sure. Thanks, Brian. There's probably a number of things we can cover there. So let me start, and I'll certainly let Tim jump in. On the expense side, we've talked about our margin improvement program. First, I'd start by saying we did see certainly some drag on labor cost, particularly contract labor. But much of that we see has been directly related to the elevated COVID cost. Certainly, as nurses have left and there's been a higher utilization of travel nurses as well as the rate that we're paying those nurses has been directly related. We saw that in earlier waves, and then we see some moderation of that as code cases go down. So as we look forward and expect coded cases to go down, we certainly expect some moderation of those costs. related to our margin improvement program, we have numerous initiatives across the organization. Many of them are not patient facing directly initiatives, but many in the supply chain area, where we have been negotiating contracts on a national basis for both supplies as well as purchase services taking advantage of our scale and leverage, which has allowed us to reduce cost. We have a number of initiatives in terms of how we are processing certain types of claims and which has allowed us to just become more efficient in terms of some other initiatives we have going on related maybe more directly to labor we have certainly invested in many of our, of how we support our nurse staffing. We have moved a lot of our recruitment into a centralized recruiting function which we have a lot of experience with from a physician recruiting function, which we centralized years ago. We're doing something similar with nursing. And we believe that, that's much more efficient, particularly in today's environment where we can attract from outside maybe the geographic region. So those are the things that initially come to mind, Tim, I'm sure there's some things I missed.

Tim L. Hingtgen -- Chief Executive Officer and Director

Yes, sure. Thanks, Brian, for the question. And I think Kevin a nice job covering kind of the opex and the strategic margin improvement program as key drivers for margin going forward. I'd like to talk about the top line, as you know, and our very focused growth objective. First of all, we certainly believe we're in a stronger portfolio and stronger markets as we outlined today on our prepared remarks. I'm really pleased with our investments taking brew, showing kind of the growth and the earnings gains that we're putting up year over year and even compared to 2019. So good organic growth in that portfolio is still something we're investing in. We have very thoughtful strategic planning processes. We've talked a lot about our transfer center. We really look forward to further optimizing that in the quarters and years to come. We get such great insights into what's happening in our markets based upon our daily activities in the transfer center, which has teed us up nicely for where we should be spending our capital next for capacity expansion, adding new service lines, recruiting new providers to further advance market share. The other avenue is related to some of our de novo projects. We've covered with you our new hospital projects, our growing freestanding ED portfolio, the joint ventures we have and are investing in, in terms of post acute care and behavioral health. All of those things, we're confident will drive strong long term opportunities in the portfolio. We've also talked about the importance of having a balanced growth philosophy. We're investing in our inpatient side of the business and the ambulatory side. I think we see that pulling through as a matter of fact, in the third quarter, we had 8% of net revenue growth in both inpatient and outpatient side of the business despite the COVID surge. So the allocation side of the business really is growing very, very nicely. So I hope that's helpful and speaks to our confidence in what we're doing to really drive long-term value here.

Operator

Next question comes from the line of Frank Morgan of RBC Capital.

Frank Morgan -- RBC Capital -- Analyst

I was hoping you could maybe break out in that other ops line. How much of that actually is attributable to the agency labor usage and then maybe talk a little bit about how that was during the quarter, at the end of the quarter, maybe where it is today. And then it also just maybe some general commentary on the non-COVID nice volumes that you have. Maybe a little color specifically between in and outpatient how that ended the quarter and then where that is today?

Kevin J. Hammons -- President and Chief Financial Officer

Sure. So we haven't specifically given an amount of what that contract labor is. It fluctuates significantly quarter to quarter because it kind of bounces around between the labor and contract labor. So, but what I would say is it's, it has increased pretty significantly sequentially over the second quarter and is above where it was in the first quarter. But we were really able to offset that if you look at the other operating expense comparatively year over year dollar amount is almost flat. So all of that increase that we had in that line item related to labor, we were able to offset with other savings in various categories, whether it is purchase services or other efficiencies that we gained largely due to these initiatives that we had, have put in place our operating initiatives or our margin improvement program.

Tim L. Hingtgen -- Chief Executive Officer and Director

Yes, Frank, this is Tim. And in terms of our non-COVID volumes in the quarter, as we pointed out, had really strong staff across all of the key indicators, improving upon our first quarter performance, the last big wave of COVID. And we saw that generally across the board. The one thing we did see is some crowding out of some inpatient surgeries in the quarter as we made way for more inpatient COVID care. We also deferred some elective orthopedic cases, which we expect to pick up in upcoming quarters as a result, just trying to preserve that capacity. Outpatient surgery was strong for the quarter. We had sequentially improved outpatient surgeries throughout the year, beating both 2020 comp and 2019's comps. So really pleased with our investments in recruiting the right specialists to our markets and building out our primary care networks of care, making sure that we're, again, really driving that market share growth on both the inpatient and outpatient side of our market.

Operator

Next question comes from the line of Josh Raskin of Nephron Research.

Analyst

This is actually Marco on for Josh. Thanks for taking the question. I was just wondering if you've seen any demographic data points suggesting that volumes could be migrating out of cities and into more suburban markets like the ones you operate in. And I would also appreciate any thoughts just more generally on what you're seeing in terms of market share changes within your footprint?

Tim L. Hingtgen -- Chief Executive Officer and Director

Thanks, Marco. This is Tim. I'll start off the answer to that question. In terms of specific data, I can't point you to one store. We do have plenty of anecdotal data and reading articles similar to I'm sure you're reading in terms of perhaps some urban flight into the suburban markets. So we believe we're positioned well. Our assets, as you know, let's take in Northwest Indiana, outside of Chicago, on the size of the Tucson market, the size of Birmingham, Fort Wayne, Naples, all these communities, I think, are well positioned for that demographic shift. Even prior to that demographic shift, we were pleased with the growth prospects in those markets, and we believe any of that migration would only be a value add.

Kevin J. Hammons -- President and Chief Financial Officer

Yes. I'd just point out, even going back to the 2020 census has certainly pointed to states that we're in like Arizona, Texas Alabama, Florida, our larger states have certainly been picking up population from other parts of the country. And then more recently, even as Tim mentioned, anecdotally. But if you look at a lot of what's being reported around real estate, you can see that markets that we're in seem to be certainly growing, and we know that there's more of a, both a demographic move toward some of the Sunbelt states, some of the lower tax jurisdictions is largely due for economic growth as well.

Operator

Next question comes from the line of Andrew Mok of UBS.

Andrew Mok -- UBS -- Analyst

Good morning. Can you speak to some of the volume trends into October and you provide some context for how non-COVID utilization is rebounding following the latest decline in COVID cases?

Tim L. Hingtgen -- Chief Executive Officer and Director

Andrew, this is Tim. I'll start us off here. In terms of our COVID, I guess, I'll say trajectory, we did see admissions peak in the midpoint of the quarter, near the end of August, actually the patient days really did not start tapering off until the latter part of September. We still are experiencing elevated levels of COVID beyond our, I guess, I'll say, our low points in previous surges. So we're still seeing pretty, I guess, elevated levels of COVID volume in our hospitals. As I said in my remarks, the care teams have just done a phenomenal job of managing us on a day to day basis, I'll say, multi times a day basis, making sure that we're taking great care of those patients. But in terms of the rebound of the non-COVID care, as we pointed out, we really held on to a good portion of that business relatively well throughout the quarter. I believe the consumer and the providers comfort level with their safety in our care settings with vaccination does lead to less of the deferral of the elective care that we had seen in previous surges. But with that being said, again, the deferred care that we're looking out for are those cases that we've delayed just to preserve our inpatient capacity for COVID cases. Our teams work regularly with the surgeons, our outreach program directors to make sure that we're bringing those cases back in as soon as the patients are ready to do so. And so from that vantage point, we do feel confident that, that business will work its way back into our systems in this quarter into the first half of next year.

Operator

Question comes from the line of Kevin Fischbeck of Bank of America..

Kevin Fischbeck -- Bank of America -- Analyst

Just wanted to maybe go to the margin discussion. I think you guys have shown some pretty good improvement in margins recently. There's a lot of moving pieces in the margin number this year between sequestration and COVID costs and everything else, contract labor, etc. Do you guys, what do you think the core margin is? I guess if we were trying to normalize everything, if we're trying to think about where you guys are on a core basis relative to that margin target that you've outlined. Is the actual reported number a pretty good estimate for where you're actually operating today? Or are there any kind of major adjustments we should be making and when we think about what, where the normalized margin is today?

Kevin J. Hammons -- President and Chief Financial Officer

Thanks, Kevin. I would say that we believe that where we're operating the margin that we're reporting today is a good barometer of where we are from an operations standpoint. We put out at the beginning of the year, kind of our medium term targets to be above 15% margin in that kind of two to four year time frame. I would say that the way we're looking at it, we're ahead of schedule. We've made some great progress on our way there. We certainly have accelerated a number of our initiatives. And so we do believe we're ahead of schedule of getting to where we think we'll, we want to be and we'll get. We're certainly, as we sit here today, I believe that over the next few quarters. We'll continue to make progress, continue to grow margins. As you can see from our guidance, we expect to be in the high 14% for the full year, which would indicate or imply fourth quarter at the midpoint, slightly above 15%. And I would say that our expectation is we'll continue to grow into 2022.

Operator

We will now turn the call over to Mr. Hingtgen for closing remarks.

Tim L. Hingtgen -- Chief Executive Officer and Director

Thanks, Jay, and thanks, everyone, for spending time with us today. In closing, I would like to mention again how grateful we are to all of our employees across the organization, our physicians, providers, regional presidents and hospital leadership teams who continue to demonstrate our true purpose of helping people get well and live healthier. I also want to thank our company's leadership team for their important role in supporting our markets and for their continued focus on successful execution. We are pleased with our strong year to date performance, and we look forward to updating you on the rest of the year in a few months. Once again, if you have any questions, you can always reach us at (615) 465-7000. Have a great day.

Operator

[Operator Closing Remarks]

Duration: 34 minutes

Call participants:

Ross W. Comeaux -- Vice President of Investor Relations

Tim L. Hingtgen -- Chief Executive Officer and Director

Kevin J. Hammons -- President and Chief Financial Officer

Brian Tanquilut -- Jefferies -- Analyst

Frank Morgan -- RBC Capital -- Analyst

Analyst

Andrew Mok -- UBS -- Analyst

Kevin Fischbeck -- Bank of America -- Analyst

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