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HCA Healthcare (HCA 2.73%)
Q2 2023 Earnings Call
Jul 27, 2023, 10:00 a.m. ET

Contents:

  • Prepared Remarks
  • Questions and Answers
  • Call Participants

Prepared Remarks:


Operator

Welcome to the HCA Healthcare second quarter 2023 earnings conference call. Today's call is being recorded. At this time, for opening remarks and introductions, I would like to turn the call over to vice president of investor relations, Mr. Frank Morgan.

Please go ahead, sir.

Frank Morgan -- Vice President, Investor Relations

Good morning, and welcome to everyone on today's call. With me this morning is our CEO, Sam Hazen; and CFO, Bill Rutherford. Sam and Bill will provide some prepared remarks, and then we will take questions. Before I turn it over to Sam, let me remind everyone that should today's call contain any forward-looking statements, they are based on management's current expectations.

Numerous risks, uncertainties and other factors may cause actual results to differ materially from those that might be expressed today. More information on forward-looking statements and these factors are listed in today's press release and in our various SEC filings. On this morning's call, we may reference measures such as adjusted EBITDA, which is a non-GAAP financial measure. A table providing supplemental information on adjusted EBITDA and reconciling net income attributable to HCA is included in today's press release.

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This morning's call is being recorded, and a replay of the call will be available later today. With that, I'll now turn the call over to Sam.

Sam Hazen -- Chief Executive Officer

Good morning. Thank you for joining the call. The company produced solid earnings in the second quarter. These results reflected continued strong demand for our services and healthy operating margins.

Across most areas of our business, we maintain the operational momentum that we experienced over the past three quarters. We believe this strength should continue into the second half of the year. Accordingly, we updated our earnings guidance for 2023 to reflect this outlook. Against the difficult comparison to the second quarter of 2022, diluted earnings per share increased to $4.29.

Same-facility volumes across the company were strong. Admissions grew 2.2% year over year, inpatient surgeries increased 1.8%, same facility equivalent admissions increased 3.7%. This growth was driven by emergency room visits, which grew 3.7% and outpatient surgeries which grew 3.3%. Other outpatient categories also grew, including outpatient cardiology procedures, with increased 5%.

The growth in volumes was broad-based across the company's divisions and diversified within most service lines. Additionally, volumes were supported by strong acuity growth of 1.6% and a favorable payer mix from commercial adjusted admissions growth of 5%. These factors drove an increase in same facility revenue of 6.3% as compared to the prior year. In the quarter, we continued to invest in our people, and as a result, we saw improvements across virtually all key labor metrics.

Turnover continued to decline for nurses and trended at an annualized rate of 17%. Nurse hiring remained strong in the quarter and for the year has increased by 9% as compared to last year. These positive results helped reduce contract labor costs 20% compared to the second quarter last year. During the quarter, we improved available bed capacity.

Instances where we could not accept patients from other hospitals declined and represented 0.8% of total admissions, down from 1.5% in the first quarter. We believe the significant investments we are making in our networks, our people and our technology agenda will provide us with the necessary resources to improve our services and provide even higher quality care to our patients. As we look to the future, we remain encouraged by both the backdrop of strong demand that we expect in our markets and our overall competitive positioning within them. HCA Healthcare will continue to use its disciplined operating culture to execute our strategic and capital allocation plans.

I want to thank our colleagues for their dedication and their overall effectiveness. So, let me close with this. I want to speak to a recent event that we take very seriously. On July 10th, we announced that we had recently discovered a list of certain information with respect to some of our patients was made available by an unknown and unauthorized party on an online forum.

We have confirmed that the list does not include clinical information, payment information or other sensitive information like passwords, driver's license, or social security numbers. Our forensic investigation is ongoing, but this event appears to be a theft from an external storage location that was exclusively used to format email messages. We are in the process of notifying all affected patients in accordance with our legal and regulatory obligations. And not unexpectedly, we have been named as a defendant in multiple class action lawsuits.

This incident has not caused any disruption to our day-to-day operations, nor do we believe it will materially impact our business or financial results. HCA Healthcare believes the privacy of its patients is a vital part of its mission and remains committed to maintaining the security of their personal information. With that, I will turn the call to Bill for more details on the quarter's results.

Bill Rutherford -- Chief Financial Officer

Great. Thank you, Sam, and good morning, everyone. I will provide some additional comments on our performance for the quarter. Consolidated net revenue increased 7% to $15.86 billion from $14.82 billion in the prior-year period.

This was driven by 4% growth in equivalent admissions and 2.9% increase in revenue per equivalent admission. We remain pleased with our team's management of operating costs even with the backdrop of inflation. Our consolidated adjusted EBITDA margin was 19.3% in the quarter. During the quarter, we completed our transaction to acquire a majority stake in the Valesco joint venture, and we are now consolidating the operations of this venture.

This reduced our consolidated margins approximately 30 basis points in the quarter. We believe this transaction not only mitigates business risk with the Envision bankruptcy proceedings but will also further support alignment between our hospital-based physicians and our hospital care teams on improving quality, patient satisfaction and efficiencies. When you consider this transaction and the 145 million payer settlement we recognized last quarter, our adjusted EBITDA margins have remained consistent between the first and second quarters. So, let me speak to some cash flow and capital allocation metrics as they remain a key part of our long-term growth and value creation strategies.

Our cash flow from operations increased 845 million in the quarter from 1.63 billion in the prior year to 2.475 billion this year. Capital spending was just over 1.2 billion. We paid 164 million in dividends and repurchased 915 million of our stock during the quarter. Our debt to adjusted EBITDA leverage ratio remains near the low end of our stated leverage range of three times to four times.

As noted in our release this morning, we are updating our full year 2023 guidance as follows. We expect revenues to range between 63.25 billion and 64.75 billion. We expect net income attributable to HCA Healthcare to range between 4.9 billion and 5.255 billion. We expect full year adjusted EBITDA to range between 12.3 billion and 12.8 billion.

We expect full year diluted earnings per share to range between $17.70 and $18.90, and we expect capital spending to approximate 4.7 billion during the year. So, with that, I'll turn the call over to Frank and open it up for Q&A.

Frank Morgan -- Vice President, Investor Relations

Thank you, Bill. As a reminder, please limit yourself to one question so we might get as many as possible in the queue an opportunity to ask a question. Bailey, you may now give instructions to those who would like to ask a question.

Questions & Answers:


Operator

[Operator instructions] And your first question comes from A.J. Rice with Credit Suisse.

A.J. Rice -- Credit Suisse -- Analyst

Hi, everybody. Maybe just -- I know Sam, in his prepared remarks, said that performance was solid across divisions. I wondered, there's been some discussion this quarter about, you know, Florida and Texas had come back early and had enjoyed strong volume. Now, the rest of the country is rebounding.

I wonder if you could comment on that. There was also a discussion from some of the managed care guys about particularly seeing strength in Medicare, Medicare Advantage, and some pent-up demand being unleashed there. I wondered if you would comment on whether you're seeing any of that as well.

Sam Hazen -- Chief Executive Officer

Thank you, A.J. As I mentioned in my comments, our volume growth was broad-based across our divisions. I think we had 13 out of 16 divisions in the company that had admission growth and adjusted admission growth. We clearly have some divisions that don't perform the same pretty much every quarter, but it was fairly broad-based across top-line metrics, admissions, adjusted admissions, payer mix improvements, and so forth.

So, a fairly consistent performance. We did have a couple of divisions that struggled, but one was isolated in Florida. The other one was isolated more out west in the Midwest. And so, for the most part, we were really pleased with the overall performance that we had across the geographies of the company.

And it's interesting, I was looking at something yesterday. We have -- from an admission standpoint, almost 72% of our hospitals have greater than 2% admission growth for the year. And this includes a little bit of pressure from COVID in the first part of the year from a comparison standpoint. We have very significant performance from the surgery standpoint as well, where almost 50% of our hospitals have inpatient surgery growth above 2%.

So, really consistent portfolio performance that speaks to the strength of our markets, I think the competitive positioning of our facilities and then the ongoing network development and physician development that we have as part of our core strategy.

A.J. Rice -- Credit Suisse -- Analyst

OK. All right. Thank a lot.

Operator

The next question comes from the line of Ben Hendrix with RBC Capital Markets.

Ben Hendrix -- RBC Capital Markets -- Analyst

Hi. Thank you. With regard to your updated guidance, can you provide some more color on what you're assuming for SWB, supplies and other operating expense, particularly professional fees through the second half versus what you've seen thus far this year? And then anything to call out that would alter typical cadence through the second half?

Bill Rutherford -- Chief Financial Officer

Yeah, Ben, this is Bill. Let me start. I think our updated guidance reflects what we're observing in the market on our year-to-date performance, which continue [Audio gap] in the growth opportunities. I think net-net, when I think about the margin profile of the company between the first half and the second half of the year, we'd expect the margin profile to be slightly better in the second half of the year.

I think our salary, wages, and benefits as a percent of revenue were running mostly where they're running year to date. Same with supplies. We have seen a little pressure on the professional fees. And we don't think that same pressure will exist in the balance of the year but will be able to meet us through that.

Ben Hendrix -- RBC Capital Markets -- Analyst

Thank you.

Operator

The next question comes from Whit Mayo with Leerink Partners.

Whit Mayo -- SVB Leerink Partners -- Analyst

Thanks. Good morning. Maybe just a question around labor. I think I heard you say, Bill, that contract labor improved maybe 20% year over year.

Did it change much throughout the quarter? Just trying to get a sense of maybe the exit rate and expectations for the second half of the year. Thanks.

Bill Rutherford -- Chief Financial Officer

Yeah. I mean, we're pleased with the labor environment. We did mention our contract labor is down 20% versus the prior year. It's improved as well sequentially between Q2 and Q1.

Our hiring metrics are up, turnover is down. And I think that portends good things for us going through the balance of the year. We mentioned before, our contract labor cost as a percentage of our SWB was under 7%. I think it was 6.8% in the quarter.

So, again, I think we're pleased with that. Especially as we go through the summer months, some of our hires get through kind of their orientation process. And then we get into the balance of the year, we would expect some continued improvement.

Whit Mayo -- SVB Leerink Partners -- Analyst

OK. Thanks.

Operator

The next question comes from Gary Taylor with Cowen.

Gary Taylor -- Cowen and Company -- Analyst

Hey. Good morning, guys. Thanks for your call. Just two quick ones for me.

Bill, I might have missed it, but I know often you kind of run through some of the managed care metrics on admissions -- you know, adjusted admission and surgeries, I'm wondering if you could rattle off a few of those for us? And then, secondly, I just want to make sure I understood on the Envision joint venture. I think we were thinking that was maybe roughly $250 million of revenue. But do all the expenses lie in the SWB line? Is that where those reside down to kind of a roughly EBITDA breakeven?

Bill Rutherford -- Chief Financial Officer

Yeah. Gary, let me start with that. Some of our managed care, I think as we mentioned in the same mentioned her comments, really favorable payer mix. Our managed care admissions were up over 4% in the quarter.

Adjusted admissions were 5%. I think we mentioned that in our prepared comments. Emergency visits managed care were up 9.8% in the quarter, and again, good acuity of case mix growth. So, we're really pleased with the payer mix that we're seeing, and that showed itself in the commercial trends.

Relative to the Valesco joint venture, your numbers are really close. About 70% to 75% of the revenue is in SWB and the rest is in other operating. And you're right, it's basically a breakeven proposition a little north of $220 million of revenue that we had in the quarter as we consolidated that.

Gary Taylor -- Cowen and Company -- Analyst

Great. Thank you.

Operator

And your next question will come from Justin Lake with Wolfe Research.

Justin Lake -- Wolfe Research -- Analyst

Thanks. Question on the pricing in the quarter. So, with strong acuity and strong and strong payer mix, maybe can you remind us, is there anything in the second quarter that I might have slipped that, drove the pricing? I would have expected it to be a little bit better given those mix items and strong commercial pricing. And then, Bill, can you just give us what you expect in the back half of the year for volumes? Would that be the guidance? Thanks.

Bill Rutherford -- Chief Financial Officer

Yes. You know, Justin, nothing specific I will call out. I mean, obviously when we do year-over-year comparisons, COVID was still an impact for us. We had roughly $40 million of COVID support payments last year that we don't have this year.

Our COVID admissions were 3% of total last year, roughly 1%. So, that's still influencing a little bit on the revenue line. On our volume projections for the balance of the year, I think, will be largely consistent. We've seen thus far, our year-to-date admissions same facility are about 3.3%.

I would think for the full year, we hover around 3%, as well for the balance of the year. Our adjusted admissions year-to-date are 5.6%. I would think by the time we finish full year, it's still 5% to 6% adjusted admissions. So, I think the volume trends we would expect in the second half of the year will be pretty consistent with what we've seen in the first half of the year.

Justin Lake -- Wolfe Research -- Analyst

Thanks.

Operator

And the next question will come from Pito Chickering with Deutsche Bank.

Pito Chickering -- Deutsche Bank -- Analyst

Good morning, guys. Thanks for taking the question. As I look at the implied revenue raise and EBITDA raise at the back half of the year, I'm trying to understand the flow-through of how much revenue raises should flow through into EBITDA upside. So, how is it tracking in sort of 2023 versus sort of pre-COVID years?

Bill Rutherford -- Chief Financial Officer

Well, when I think about that, when I look at the rate, it's based on where we perform them in our view of the position going forward. We do expect continued improvement in the labor market. But as I said, I think as a percent of revenue, we hold, I think the margin profile overall for the second half of the year will be slightly better than the margin profile we saw in the first half of the year. And that, all in all, has contributed to the guidance raise.

I remind you, we've raised our guidance almost the midpoint of our EBITDA guidance, roughly $450 million from where we turn the calendar. So, I think all that's reflective in our considerations right now.

Sam Hazen -- Chief Executive Officer

Yeah. And, Bill, let me add a point here. I think it's a relevant point. Obviously, we've dealt with a fairly unprecedented labor market over the last three years or so.

And we do believe, as Bill indicated earlier, it's moderating. We've also dealt with sort of an unprecedented hospital-based physician dynamic at a macro level. And if you just take a snapshot of where we are six months into this year versus where we were pre-pandemic when neither of these macro forces were in place, we've actually increased our margins by comparison to 2019. So, I think it's sort of a testament to the ability of the company to adjust operationally to dynamics and continue to move forward with our strategy.

As we've mentioned before, we think our competitive positioning has improved compared to where we were pre-pandemic. Our market share has also improved during that time period. So, we continue to believe that the company has the wherewithal to adjust to these factors, continue to move ahead in a very positive way and generate the results that we all want.

Pito Chickering -- Deutsche Bank -- Analyst

Great. Thanks so much.

Operator

And your next question comes from Ann Hynes with Mizuho Group.

Ann Hynes -- Mizuho Securities -- Analyst

Thanks. Good morning. I know it's early, but do you have any observations on how Medicaid determinations is impacting your business? I know one of your bigger states, Texas, started early. It sounds like it's been a little bit messy.

So, any early observations? And can you remind us if you have anything from Medicaid determinations in your guidance? And do you think this process is going to be an overall positive or negative for HCA?

Bill Rutherford -- Chief Financial Officer

Yeah. Thanks for that. It's a good question. And you're right, it is still early, and we've got a pretty organized approach to not only continue to watch the market but respond on there.

So, we haven't seen any negative or any material impact on this today. We think what we're seeing many of the patients who are receiving determination, that, you know, there's some opportunity to continue to get them reenrolled in Medicaid, some of them are more technical. They either didn't complete an application or some other aspect of that. So, our teams are trying to identify those individuals as best they can, assist them in gaining coverage, which remain encouraged by many of the studies that the people are being redetermined off, who will qualify either for coverage in an employer sponsor plan or qualify for coverage in the health insurance marketplace.

And so, we'll continue to watch that as that unfolds. But no impact right now. Nothing in our guidance is assumed for Medicaid redetermination. We believe over the long run, you know, there could be some positive trends from this but we'll just have to wait to see how that plays out.

Operator

And the next question comes from Kevin Fischbeck with Bank of America.

Kevin Fischbeck -- Bank of America Merrill Lynch -- Analyst

Great. Thanks. I wanted to just maybe dig in a little bit more to kind of how you're thinking about the volume growth in the back half of the year. I guess, you know, when you think about [Inaudible] trending relatively similar in the back half versus the first half, I guess the way we had been thinking about it any way was that last year, it felt like as COVID spiked at the beginning of the year and then became less and less of an issue that volume to started to kind of normalize in the back half of the year.

And so, that maybe the comp would be a little more difficult as you got into Q4 and if the growth rate might slow. So, I just want to think about how you're thinking about volume growth and where you are versus maybe long-term trend lines and things like that. How do you put that into context about thinking this rate of growth will continue in the back half of the year?

Sam Hazen -- Chief Executive Officer

Kevin, this is Sam. Let me give you sort of the backdrop, we think, of what exists for us with respect to volume. And this is more of a general commentary. I'll let Bill sort of reconcile the back half of the year to the first half of the year with numbers.

I'm not sure I can do that at this particular point in time. As we said before, and we continue to believe this we feel that within our markets, there's unique attributes that are driving solid demand for healthcare services. Population growth continues to be strong in Texas and Florida, in Utah, Nevada, South Carolina, pretty much Tennessee. Across the board, we're experiencing population growth within our markets.

The second point is we're investing very significantly in our strategy and our positioning within these communities so that we can respond to our patient needs, put our facilities in the best position to grow. And we think that's going to help us sustain market share growth as we move forward. What we're seeing is that our overall volume assumptions are supported by acuity. Acuity has maintained, some of that strategic, some of that, I think, is the dynamics that exist within the markets.

And then, the second support mechanism that's in place, and we view this positively, is the payer mix dynamic. We have seen throughout the first half of the year, commercial admissions outpaced our total admissions. Again, we think that's reflective of a strong economy and job positioning that a lot of people have in our communities, as well as the exchanges. And so, we think those will continue on into the last half of this year.

And we're optimistic that those will continue on into the future, at least in the near term. So, Bill, you can maybe try to reconcile --

Bill Rutherford -- Chief Financial Officer

I'll just say, I mean, when we think about projecting going forward, we try to take all of those factors into consideration, as Sam mentioned, and where we're seeing year to date. Mind you, when we originally said our guidance, we anticipated 1% to 2% admission growth, mid single-digit outpatient growth. So, that's still hovering around 2% to 3% equivalent admission growth was our expectation. And given, you know, the fact that we're seeing north of 3% admission growth and 5.5% adjusted admission, that's informing our position for the balance of the year.

So, I still think around three is a good number for the full year now based on the first six months of the year. We're continuing to see good outpatient revenue growth. And so that should support this 5% to 6% equivalent admission expectation for the full year.

Sam Hazen -- Chief Executive Officer

Yeah. And, Bill, if I can add one thing. With respect to our investments in our networks. We have, at this particular juncture, the largest pipeline of projects that are in motion, including our outpatient development components which are very robust, as well as other inpatient and facility needs there.

So, our pipeline from an organic standpoint as far as capital that we will see hit the market in latter '23, '24, early '25 is more robust than we've seen in pretty much recent years.

Kevin Fischbeck -- Bank of America Merrill Lynch -- Analyst

Great. Thanks.

Operator

The next question comes from Brian Tanquilut with Jefferies.

Brian Tanquilut -- Jefferies -- Analyst

Hey. Good morning, guys. Bill, you touched on the impact of Envision being a 30 basis-point drag. I know there's some -- a lot of noise happening with American Physician Partners and just stuff moving around the physician staffing.

So, as we think about that drag, is there opportunity to bring that up? Or is that like a more structural thing where you've had to bring in, you know, in-house capabilities for physician staffing?

Sam Hazen -- Chief Executive Officer

Yes. This is Sam. Let me start with that, and Bill can color in here. As I mentioned, the backdrop in the hospital-based physician space has been very difficult over the past few years because of multiple factors.

And for us, in the short run, we have had to respond to these difficulties to maintain capacity and service availability and so forth. And so, we did what we had to do to make sure that our business continue to move forward appropriately. And for the most part, we've overcome these pressures and been able to grow, and we've increased our earnings expectations for the year in the face of some of these challenges. As Bill mentioned, we don't anticipate the same level of increases and pressures in the last half of the year, although we'll have some.

But it's not going to nearly be what we've experienced in the first part, we don't think. And we do believe with the Valesco operations, we now have a platform that gives us the potential to respond better to these type of challenges and possibly integrate hospital-based physicians into our hospital operations even more effectively, producing better clinical performance efficiency and even growth, we think. And so -- and I'll say this again, I said it earlier, we have a pattern of responding to different kind of operational challenges, whatever they happen to be. We've had labor, as I mentioned.

We've had physician costs. Currently, we've had uninsured in the past. And we've tended to overcome them. In the short run, sometimes they can create an individual pressure.

But I think the scale of HCA, the resources that we have and the ability to execute allows us to move through some of these pressures over time and get where we want to be.

Brian Tanquilut -- Jefferies -- Analyst

Thanks, Sam.

Operator

And the next question comes from Lance Wilkes with Bernstein.

Lance Wilkes -- AllianceBernstein -- Analyst

Great. Thanks. I've got a strategic question for you on digital health and AI. I was just interested in the initiatives that you're kind of putting in place through the organization at this point, where you're maybe investing on the venture capital side here.

And long term, what do you see is the opportunity for this, whether it's potentially reduced compensation or an ability to expand volume across the footprint?

Sam Hazen -- Chief Executive Officer

This is Sam. We have a growing digital agenda in our company, and I'm very excited about what the prospects are for us around that. We are investing in a new clinical system, which we think is going to allow us to move information to the cloud more efficiently, and a matter of fact, move standard data sets into the cloud so that we can then use big data even more effectively and infuse that back into the care process. We will couple our digital agenda with something we're calling care transformation innovation.

And inside of that, we believe we have opportunities to improve care processes, eliminate a lot of the variation that exists today in our company, create better quality and, at the same time, more efficiencies. Artificial Intelligence, we believe, will play a huge part in that. It's way early for us to; know exactly what that will be and how that will influence our agenda, but we're encouraged about the prospects for it. We are partnering with some very sophisticated companies to help us push through this in ways that I think will accelerate our agenda and inform it with more expertise than what we have internally.

So, we're excited about what this can yield for us as we push into our next life cycle, if you will. And we'll wait to see what artificial intelligence, in fact, can do. But we view it as a positive, you know, potential for us in a very significant way.

Lance Wilkes -- AllianceBernstein -- Analyst

Great. Thanks.

Operator

The next question comes from Andrew Mok with UBS.

Andrew Mok -- UBS -- Analyst

Hi. Good morning. I just wanted to follow up on the pricing discussion maybe from a different angle. Revenue per outpatient equivalent, looks like it was down about 1% in the quarter, which seems to be weighing on strong inpatient pricing up 6%.

Can you help us understand the pricing and mix trends across your outpatient platform that are causing that unit revenue metric to blend down this year? Thanks.

Bill Rutherford -- Chief Financial Officer

Well, I'd say we're pleased with the outpatient growth that we're seeing. If you look at the overall outpatient growth that we have, it's -- our expectation was mid single digits. We're well north of that in the quarter and on a year-to-date basis. You know, there's always a little bit of a mix issue that occurs.

Our emergency room volume was up, what, 3.7%, which were a lot of are outpatient. Our outpatient surgical growth was up 3.3% in the quarter. So, I think those are really good stats. On the outpatient revenue, per unit.

There's always a blend between surgical, emergency room and diagnostic. But I would say, overall, we're very pleased with the outpatient overall growth that we are seeing.

Sam Hazen -- Chief Executive Officer

Yes. And, Bill, just the second quarter overall outpatient revenue growth was actually up over the first quarter. So, we are seeing some acceleration. There's a lot of moving parts, as Bill just alluded to, to outpatient revenues between physician, clinics, urgent care, all the way up to outpatient cardiology procedures, which tend to be our highest reimbursed type of procedures.

And so, the mix of that can influence the outpatient. We tend to look at it in the aggregate. And for the most part, our aggregate revenue growth has been stronger in the second quarter than it was in the first quarter. And then, within sort of the pricing elements, we continue to get the targeted price increases that we want in both our inpatient and our outpatient businesses.

So, it's more, to Bill's point, sort of the mix and the mixture of all of the different components in a way that has produced solid growth for us.

Andrew Mok -- UBS -- Analyst

Great. Thank you.

Operator

Next question comes from Calvin Sternick with JPMorgan.

Calvin Sternick -- JPMorgan Chase and Company -- Analyst

Hey. Good morning. I wanted to ask about the commercial rate cycle. I think last quarter, you said you guys are about two-thirds of the way through 2024 and about one-fourth of the way through 2025.

Can you give us an update on the progress and how those rate discussions are evolving?

Bill Rutherford -- Chief Financial Officer

Yes. They're evolving pretty consistent. As we just mentioned, we're continuing to see rates in kind of the mid-single digit level. As far as contracted for '24, I think we're a little north of 70% for '24 now.

And I think our efforts continue. I think our relationships with our major payers continue to be strong, and we're pleased with the progress we're making in that area.

Operator

And the next question comes from Scott Fidel with Stephens.

Scott Fidel -- Stephens, Inc. -- Analyst

All right. Thanks. Interested just as against the backdrop where the managed care payers are seeing the higher medical cost trends this year, whether you're seeing any changes in behaviors when interfacing with them from a prior authorization or utilization management-type perspective? Or are things pretty consistent there? And then, just a quick follow-up, just on the slight raise in the capex. Is that just related to the general broad-based investments that Sam just talked about? Or are there any specific projects that you would cite around the update to the capex guide? Thanks.

Bill Rutherford -- Chief Financial Officer

Yes, let me try to take both of those. I think as we maybe mentioned in the past, you know, as you think about authorization and medical necessity reviews, those activities have picked up again as -- you know, during the COVID period of time, those have eased a little bit. But we still see a lot of friction, if you will, as you go through that effort. We work with our payers to try to resolve those appropriately, make sure that we defend our positions where necessary.

But there is a level of activity that both us and the payers have to devote to try to smooth through that process. But we tend to be able to work our way through it. On the capex, I think it's simply reflective of the opportunities we see in the market to continue to deploy capital for growth. Fortunately, we continue to see really strong cash flow to be able to support that capex.

And again, I think it's reflective of the growth opportunities we see in the market.

Sam Hazen -- Chief Executive Officer

And, Bill, as we mentioned on the last call, we have acquired some land for future expansion in some of these fast-growing markets that we serve, and that puts some upward pressure on our capital spending. But we believe those are long term good decisions for us.

Operator

The next question comes from Jason Cassorla with Citi Group.

Jason Cassorla -- Citi -- Analyst

Yes. Great. Thanks for taking my question. Just wanted to ask a little bit more on the labor front.

Thinking about all the efforts and programs you put in place contributing to the better turnover and hiring trends, I guess, is there a way to help frame what inning you're in as it relates to these efforts? Where do you like to see some of the outputs on turnover retention kind of move to? Or any other thoughts on the labor front and the trajectories there? Thanks.

Sam Hazen -- Chief Executive Officer

Yes. This is Sam. Thank you for that question. As I mentioned, we have invested very heavily in our people agenda over the past few years.

We've increased our capacity within our recruiting function. Our recruiting efforts are yielding strong hiring, and we believe that will continue on into the latter half of the year. Our retention efforts with respect to responding to our employees' needs so that they have the necessary resources and tools to be effective in their day-to-day jobs, we're getting better at that. That's helping turnover.

Turnover is approaching pre-pandemic levels, especially in the nursing area. We are a few points above pre-pandemic. But if you annualize the second quarter turnover, it would suggest less than that. So, we're encouraged by that, and we do believe we have opportunities to continue improvement in that area.

With contract labor, as Bill mentioned, we expect to see improvements as we move through the last half of the year. And then, I'm very excited about our workforce development initiatives. We continue to invest heavily in Galen College of Nursing. They're expanding each quarter, it seems, into new markets and establishing new relationships and new opportunities for people and for our company.

And then we're also investing in our -- what we're calling our Centers for Clinical Advancement, which is our ongoing clinical education for our people so that they can upskill their capabilities and competencies and put them in a position to either deliver better care or grow in their own individual career. So, what inning are we in? We're in the middle innings in some of the areas. And so, we will wait to see how the latter half of the year plays out. But all in all, I think tremendous results.

We're very competitive, we believe, across the organization with our compensation and benefit programs. And as I mentioned earlier, we've been able to navigate through these difficult periods and maintain margins. I think our labor costs -- again, if you just look at 2019 as a proxy, our labor cost in 2023 are below as a percent of revenue 2019. And again, that's in the very -- in the face of a very difficult labor market.

Jason Cassorla -- Citi -- Analyst

Great. Thank you.

Operator

The next question comes from Jamie Perse with Goldman Sachs.

Jamie Perse -- Goldman Sachs -- Analyst

Hey. Thank you. Good morning. Can you comment on seasonality expectations for the third quarter? Anything beyond normal seasonality from a headwind or tailwind perspective that we should be thinking about? And I think normally, revenue is down slightly and EBITDA down maybe mid single digits to high single digits.

Is that the right way to be thinking about the third quarter? And anything in July that's informing that? And then, there was an earlier question on backlog that may not have been fully answered. I'd love your thoughts on that as well. Thank you.

Sam Hazen -- Chief Executive Officer

We mentioned at the end of the fourth quarter that we were starting to see normal seasonality patterns materialize. And we've seen that so far through the first half of this year, and we think that will continue on into the second half of this year. The third quarter is not as strong as the fourth quarter. The fourth quarter is always the strongest quarter of the year for us, given the outpatient activity and deductibles and so forth.

And so, we think the third and fourth quarter will be similar in patterns to pre-pandemic seasonality. And that's what's reflected in our guidance.

Operator

And the next question will come from Steven Valiquette. Your line is open.

Steve Valiquette -- Barclays -- Analyst

Great. Thanks. Good morning, everybody. So, I guess as a follow-up to just some of these prior questions on the labor and commercial rate update.

There was some conjecture for HCA that the company didn't have, you know, quite as many commercial payer contracts up for renewal for fiscal '23 to capture some better rates for elevated labor costs, which you had more coming up for renewal in '24. Now that the noise levels kind of died down somewhat here in mid '23 on overall labor cost pressure versus -- certainly versus 12, 15 months ago, I guess the question is do you still have confidence to potentially capture potentially slightly better than average commercial rate updates for fiscal '24? Is labor pressure maybe still being the key variable within those discussions? Or are those going to be a little bit tougher now, given that some of the pressure is subsided. Just want to get your kind of latest thoughts around that. Thanks.

Sam Hazen -- Chief Executive Officer

Well, this is Sam. Bill indicated that we're 70% contracted on '24 around our targeted escalation objective. Labor costs, as you mentioned, are moderating some. Yes, there's still inflationary pressures underneath it, as one would expect.

Now, we have physician cost pressures with respect to pro fees. And our belief is that, that will have to be paid for by someone. And so, that will become a new factor in our thinking and our justification for appropriate price increases. So, our cost are not just one category.

We have multiple categories, as you can see on the income statement. And all of that factors into our considerations when we're negotiating.

Operator

And the next question will come from Joshua Raskin with Nephron Research.

Josh Raskin -- Nephron Research -- Analyst

Hi. Thanks. Good morning. Were there any meaningful differences in the payer mix on the outpatient side, you know, an obvious focus on Medicare and specifically Medicare Advantage volumes.

And are you seeing anything in the Medicare market that would support higher levels of demand than we saw last quarter or the quarter before, anything that you feel like is inflecting?

Bill Rutherford -- Chief Financial Officer

Yeah, Josh, when I look at kind of the admissions versus adjusted admissions between the payer categories, they're comparable. Our Medicare adjusted admissions were up 5%. Our managed care adjusted admissions were up 5%, as we mentioned earlier, you know, fueled by emergency room growth. So, I think the trends are pretty comparable among the payer categories.

And that's strengthening payer mix, that's, I think, positive trends for us. So, nothing else underneath the outpatient area that I would distinguish, other than we continue to see good commercial ER traffic. Our commercial outpatient was up pushing close to 4% as well. So, again, I think they're pretty comparable in terms of the general trends we're seeing.

Sam Hazen -- Chief Executive Officer

I would say, Bill, just to put a little bit of color on the outpatient. Our commercial outpatient revenue growth is clearly outpacing our Medicare outpatient revenue growth. Some of the adjusted admissions are influenced by some of the calculations, if you will. But we are seeing really solid commercial outpatient revenue growth, again, influenced by the ER, influenced by surgeries, which are represented by roughly 50% to 55% commercial.

So, good growth there. And all of that yields, you know, solid commercial revenue growth.

Josh Raskin -- Nephron Research -- Analyst

All right. Thanks.

Operator

There are no further questions. At this time. Mr. Frank Morgan, I turn the call back over to you.

Frank Morgan -- Vice President, Investor Relations

Bailey, thank you so much for your help today. Thanks, everyone, for joining our call. I hope you have a wonderful rest of your week. And I'm around this afternoon if we can answer any additional questions you might have.

Thank you very much. Have a great day.

Operator

[Operator signoff]

Duration: 0 minutes

Call participants:

Frank Morgan -- Vice President, Investor Relations

Sam Hazen -- Chief Executive Officer

Bill Rutherford -- Chief Financial Officer

A.J. Rice -- Credit Suisse -- Analyst

Ben Hendrix -- RBC Capital Markets -- Analyst

Whit Mayo -- SVB Leerink Partners -- Analyst

Gary Taylor -- Cowen and Company -- Analyst

Justin Lake -- Wolfe Research -- Analyst

Pito Chickering -- Deutsche Bank -- Analyst

Ann Hynes -- Mizuho Securities -- Analyst

Kevin Fischbeck -- Bank of America Merrill Lynch -- Analyst

Brian Tanquilut -- Jefferies -- Analyst

Lance Wilkes -- AllianceBernstein -- Analyst

Andrew Mok -- UBS -- Analyst

Calvin Sternick -- JPMorgan Chase and Company -- Analyst

Scott Fidel -- Stephens, Inc. -- Analyst

Jason Cassorla -- Citi -- Analyst

Jamie Perse -- Goldman Sachs -- Analyst

Steve Valiquette -- Barclays -- Analyst

Josh Raskin -- Nephron Research -- Analyst

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