CYH - NYSE

Good day, and welcome to the Community Health Systems Second Quarter 2025 Earnings Conference Call. [Operator Instructions] Please note this event is being recorded. I would now like to turn the conference over to Mr. Anton Hie, Vice President of Investor Relations. Please go ahead, sir.

Thank you, Chuck. Good morning, and welcome to Community Health Systems Second Quarter 2025 Earnings Conference Call. Joining me on today's call are Tim Hingtgen, Chief Executive Officer; and Kevin Hammons, President and Chief Financial Officer. Before we begin, I must remind everyone 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 under headings such as Risk Factors in our annual report on Form 10-K and other reports filed with or furnished to the SEC. 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. We've also posted a supplemental slide presentation on our website. All calculations we will discuss today exclude gains from early extinguishment of debt, impairment gains or losses on the sale of businesses and expense from business transformation costs. With that said, I'll turn the call over to Tim Hingtgen, Chief Executive Officer.

Thank you, Anton. Good morning, everyone, and thank you for joining our second quarter 2025 conference call. Before we get to the quarter's results, I want to address the announcement made yesterday afternoon that I decided to retire at the end of September. I'm stepping back from my role as CEO for personal reasons, the most important one being that I want to dedicate more time to my family and personal pursuits. And while I have loved the opportunity to serve as the leader of an organization that is devoted to helping people get well and live healthier, the job of CEO requires the highest degree of time, energy and commitment, and my family has very generously supported me in my commitment to giving everything I have to leading this organization. I've been thinking about that a lot this year. I want to be more present for them at this stage of my life and at this stage in theirs. I also have some personal pursuits that I want to explore while I'm still young enough and eager enough to try new things. This is not a decision that was made easily or quickly or without regard to what's best for CHS. I wrestled with whether to retire and when to retire in part out of a sense of loyalty to the organization, but even more than that, out of my sincere desire to continue to be a part of the progress happening in this company and the opportunities and achievements I still see ahead. Those will continue to happen under Kevin's leadership, I am sure. But after thinking about it a lot and consulting with my family, this is the appropriate decision. Let's call it a difficult, honest and for me, a necessary choice. I'll be here through the end of September to support a seamless transition. But truthfully, Kevin could step into the role of CEO today and things would be just fine. He knows CHS as much as anyone, and he cares deeply about our company, our people and the patients who choose and rely on CHS health systems for their medical care. I want to thank the CHS Board for their faith in me and the CHS team for the privilege of being their leader and thank you to our investors for your confidence in CHS. So now with that, let me make just a few brief remarks about the quarter, and then Kevin will add quite a bit more detail and color about our results and what we see ahead, including potential impact from the Big Beautiful Bill. In the second quarter on a same-store basis, net revenue increased 6.5% year-over-year. Inpatient admissions were up 0.3% and adjusted admissions declined 0.7% with a 2.5% decline in surgeries and a 1.9% decline in ER visits. While patient volumes were lower than expected and hampered our overall earnings results, we are confident that our past development in capital investment strategies have positioned CHS health systems very well to capture patient demand once consumer confidence returns, and it always has. Our development strategies include physical capacity and service line expansions with a balanced focus on both inpatient and outpatient care. And we are intentional about broadening the footprint of our health systems through the ongoing recruitment of primary care, specialty physicians and other providers. Specifically, through our year-to-date recruitment activities, we have over 200 providers currently scheduled to commence in the second half of 2025, including backfilling for the departure of certain independent specialists. We have a strong clinic services operations team, and we are committing significant resources towards ensuring the successful and rapid ramp-up of our newest providers. Recent service line and capacity expansions in Knoxville, Naples, Laredo, Birmingham and other key markets continue to ramp up and gain market share, and we have several new outpatient access points set to open in the coming months, including new ambulatory surgery centers in our Birmingham, Boley and Tucson markets. Today, CHS operates more than 40 ASCs, a critical component of our market growth strategy and being well positioned to grow and serve consumer demand. We also continue to make progress on other strategic initiatives. Since our last earnings call in April, we completed the divestiture of Cedar Park Regional Medical Center in Texas and continue to improve our maturity and leverage profile through successful debt refinancing and retirement transactions. Now I'll turn the call over to Kevin. And as I do, I just want to once again express my full confidence in his upcoming leadership of Community Health Systems. Kevin?

Thank you, Tim, and good morning, everyone. Before I begin with the review of financial and operating results, I want to take a moment to acknowledge Tim's contributions to CHS over the past 17 years. Since joining the company in 2008, Tim has brought an invaluable amount of experience and insight into our organization and has been instrumental in leading the development of regional health care networks across the country. Tim's long track record of success as an operator, his leadership qualities and his natural way with people have been an asset to CHS and all of our teammates from us here at the corporate headquarters and throughout our entire organization. For me personally, Tim, I want to say that it's been my pleasure to have been your partner here at CHS and to serve alongside you as your CFO. I believe I can speak for everyone when I wish you the best in your future endeavors. Turning to the results for the second quarter. CHS executed well on many of the controllable aspects of our business, such as supplies expense, wage rate growth and overhead costs. However, we believe that external factors have affected the demand for health care services across our markets over the past few months. Last quarter, we noted some deterioration in our acuity mix versus expectations with softer demand for elective surgical procedures within our commercial book. While we had expected the mix profile to improve with the typical seasonal factor of commercial patients meeting their deductibles and the flu volumes dropped off, this improvement did not materialize in the second quarter as expected, which led to some loss of operating leverage and slight degradation in EBITDA margin year-over-year and versus our forecast. Despite the adverse volume and mix profile, CHS continued to make good progress on strategic initiatives, as Tim noted in his prepared remarks. On June 30, we completed previously announced divestiture of our 80% ownership in Cedar Park Regional Medical Center to the minority partner, Ascension Health for $436 million. And in May, we successfully refinanced all $700 million of our outstanding 8% Senior Secured Notes due 2027, using proceeds from our offering of a new 10.75% Senior Secured Notes due 2033 and also tendered and redeemed $584 million principal value of our outstanding 2028 unsecured notes using $438 million in cash on hand. Turning back to operating results for the second quarter. Same-store net revenue increased 6.5% year-over-year and was primarily driven by rate growth, including the recognition of revenue under Medicaid state-directed payment programs in New Mexico and Tennessee, a portion of which was related to prior periods. Same-store inpatient admissions increased 0.3% year-over-year, while adjusted admissions declined 0.7%. Same-store surgeries declined 2.5% and ED visits were down 1.9%. Adjusted EBITDA for the second quarter was $380 million compared with $387 million in the prior year period and included approximately $75 million in net contribution from the recently approved state-directed payment programs in New Mexico and Tennessee. Margins for the second quarter was 12.1% versus 12.3% in the prior year. Turning to expense management, we continue to perform well on labor cost with an approximate 4% year-over-year increase in average hourly wage rate, which was consistent with our range of expected growth for the year and again includes the impact from significant growth in the number of employed positions, which was consistent with our expectations. Contract labor expense at $40 million was down to approximately $5 million year-over-year on a consolidated basis and was flat sequentially. We also continue to perform well on supplies expense, which was down year-over-year and when adjusting for the impact from the new SPP programs in New Mexico and Tennessee was essentially flat as a percentage of net revenue with the prior year period. We believe there remain opportunities in this area as we stabilize and mature our new processes with our ERP. Medical specialist fees were $152 million in the second quarter, essentially flat year-over-year on a consolidated basis and representing 4.9% of net revenues, consistent with the prior year period. Cash flows from operations were $87 million for the second quarter and $208 million for the year-to-date. Note that cash flows from operations as reported includes $74 million in outflows for taxes on gain on sale, primarily for the Lake Norman and ShorePoint transactions, which were paid out of divestiture proceeds and were not considered in our annual guidance. When excluding this figure, our cash flows from operations were $282 million for the year-to-date and free cash flows for the second quarter were marginally positive. Note that the funds from the new state-directed payment programs in New Mexico and Tennessee likely beginning to flow in the third quarter, and the company should also see positive free cash flow in the back half of the year. Additionally, we anticipate receiving the previously discussed contingent consideration related to the Tennova-Cleveland divestiture and the proceeds from the sale of our reference lab business to Labcorp by the end of this year. We have received many inquiries from the investment community about the financial impact from the recently signed Budget Reconciliation or One Big Beautiful Bill Act. Based on our analysis, impacts to state-directed payment programs will be phased in beginning in 2027 through 2038. We project the combined impacts from lowering the provider tax threshold and the phase down to Medicare linked rates across CHS states will reduce EBITDA by approximately $300 million to $350 million cumulatively over the next 13 years with no impact in 2025 or 2026, an immaterial impact in 2027 and then building from there. Our estimate reflects the estimated net reduction relative to total Medicaid reimbursements based on current Medicaid reimbursement rates. Our analysis does not take into account any impact from Medicaid work requirements or the various provisions that could affect enrollment in ACA plans such as expiration of the extended tax credits since these are much more difficult to predict. Additionally, this analysis does not assume any benefit from the proposed rule fund due to the uncertainties of how those monies will be distributed nor do we assume any mitigating factors from expanded SDP programs, cost reductions, potential service line changes, strategic investments or other actions that we make in order to offset the financial impact to CHS. In the upcoming months, CHS will support industry efforts to aggressively pursue legislative and administrative fixes to the bill. We assume the opportunities to do so will increase as voters better understand how the cuts affect their households. On the subject of the Budget Reconciliation Act, I think it is also important to note that the interest deduction under Section 163(j) of the IRS code, which we have discussed on several occasions in the past, was restored, which will increase the amount of interest CHS can deduct for tax purposes. And along with the accelerated depreciation provisions will have the benefit to us of lowering our annual cash taxes by approximately $40 million to $60 million beginning next year. Now moving on to our 2025 financial guidance. Based on our operating results through the first half of the year and the lower-than- expected volume growth heading into the third quarter, combined with the impacts in the second half of the year from the recently completed Cedar Park divestiture and the new state-directed payment programs we are tightening our adjusted EBITDA range for the full year 2025 to $1.45 billion to $1.55 billion. While we are pleased to receive the additional funding in New Mexico and Tennessee, which will be helpful to maintain service lines in the markets we serve, we believe it is prudent to take a more conservative approach to the underlying business given the impact from macro factors that we have observed in the second quarter. This concludes our prepared remarks. So at this time, we will turn the call back over to the operator for Q&A.

[Operator Instructions] And the first question will come from A.J. Rice with UBS.

I want to just wish Tim best wishes going forward. And Kevin, congratulations. Maybe I'll ask about 2 items on the guidance. Volumes, obviously, it seems like those are coming in a little more sluggish than expected. To what extent did you make a tweak in your second half expectations, if you did on volumes? And maybe talk about the dynamics you saw intra-quarter? Was there any variation intra-quarter on that? And then on -- also on the guidance, the operating cash flow, I know year-to-date, your free cash flow, I think it's about $200 million -- or operating cash flow rose $200 million. And I think the guidance calls for $600 million to $700 million. I know there's some unusual items like the DPP program and the way you get paid for that. Can you just bridge us a little bit from what you're seeing in the first half and how you get to that second half number?

Thanks, A.J. Let me start off. In terms of volume, intra-quarter, really, if we go back to March of this -- of the first quarter, we began to see some decline in consumer confidence. The consumer confidence consistently declined in April, May and June to the point where we're seeing now the lowest consumer confidence probably since COVID levels. So I'm not sure we saw a significant decrease kind of month-over-month, but certainly, as the consumer confidence is a leading indicator and it has continuously declined, we're taking that into consideration. I will say that as we exited June, we did see -- kind of the final week of June beginning to see some recovery in volume back to prior year levels. And as we look out into kind of this first part of July coming into the third quarter, although the levels are not where we had maybe originally anticipated, we are starting to see some stabilization in our volumes relative to prior year. If we look out over the course of the year, where we had maybe originally guided towards a 2% to 3% adjusted admission volume for the year, I think a new updated guidance would look more like 0% to 1% adjusted admissions for the year. Currently, we're at 1% year-to-date. So hopefully, that gives you a little bit of color around the volume trends. Cash flow, as we think about our guide kind of remain the same. A couple of things I'd point out. Our adjusted cash flow from operations, we reported $208 million, but that did include the $74 million cash tax payment on the gain on sale. That cash comes out of the divestiture proceeds. When you add that back in, cash flow from operations in the first half of the year is $282 million, which is almost halfway there for our full year guide -- at least the low end of our full year guide. And typically, our fourth quarter is by far the largest cash flow generating quarter of the year. The DPP programs that were approved in the second quarter in New Mexico and Tennessee, those were approved just in the final days of the quarter. We've not received any of that cash yet. So those payments will be coming in the back half. So with those payments and historically better fourth quarter cash flow generation, we expect to be able to hit the range with effectively our EBITDA guidance staying relatively flat from where we were at the beginning of the year. And our year-to-date cash flow, I think, will be positive in the back half of the year as well.

If I could just jump in with one follow-up. There have been some pending DPP programs that were relevant to you, Indiana, Alabama and to a lesser extent, Florida, potentially topping up their program. Is there any update on the status of those in light of the One Big Beautiful Bill?

There is. So Florida has submitted for an update to their rate under their existing program. That submission was in on time, and we would expect that to be approved, and there should be a small tailwind for us at the point in time that gets approved. Indiana, likewise, has submitted their preprint to CMS for a new state-directed payment program, which will replace their provider tax program that currently exists in the state. We would expect that to be a much more material benefit to us. That preprint was submitted before the deadline, and we fully expect that, that one will also be approved. We don't have the ability to really estimate the amounts, and we don't do that until those programs are approved, but the insights we have today and given our footprint in the state of Indiana, we would expect that to be a material benefit to us. In terms of Alabama and Arkansas, they are not that far along yet, but we understand there may still be a path for them. It's a little less clear to us at this point, but I know those states are still working on some opportunities.

Your next question will come from Brian Tanquilut with Jefferies.

Tim, congrats on the retirement and Kevin, good luck. Maybe my first question, as we think about what the right run rate is for earnings, thinking about given the DPP from the quarter, I'm thinking like $305 million. Is that the right way to think about it or maybe slightly higher than that if we back out the prior period contribution from the Tennessee DPP? So can you just walk us through how we should be thinking about the right run rate for EBITDA going forward?

Sure, Brian. Thank you. $305 million, I think, would be -- is too low because that's really taking out the entire DPP money that we recognized this quarter. You would want to include the current period quarter portion of that, call that roughly $30 million. So starting at $335 million -- but even at that point, volumes in the second quarter were really depressed. And we don't think that's the current run rate, particularly, as I mentioned, as we're exiting the quarter and seeing some visibility into some stabilization. I would say that the real run rate in our mind is probably something in the $360 million to $375 million as a starting point. And then as we get back to positive volume growth. And we believe, as Tim mentioned in his remarks, there are times when we go through periods where volumes seem to dry up, but they always come back. We believe that most of what happened this quarter was care that's being deferred for financial reasons, the patient behavior, but that will come back. So kind of as a baseline starting point in the $360 to $375 range and then opportunity to grow from there.

That makes sense. And then maybe, Kevin, just to double-click on your comment on the OBBBA impact. Maybe if you can share with us just how you are thinking about that number, meaning like what assumptions go into that or maybe how we should be thinking about kind of trying to build that ourselves?

Yes. I mean there's some probably pretty complicated math behind those. So we really went through kind of state-by-state exercise, taking a look at which states are expansion states, which states are non-expansion states, ratcheting down both the rate of -- Medicaid rate for where we have commercial -- average commercial rate on Medicare and then the states that are expansion states that have taxes above the 3.5%. Those get ratcheted down, I think, 50 basis points each year beginning 2028.

The next question will come from Ben Hendrix with RBC.

With the recognition of the DPP revenue from Tennessee and New Mexico and then also the developments on the commercial elective weakness, maybe you could kind of just recap the bridge to the revised 2025 EBITDA guidance for us.

Sure, Ben. We started, call it, the midpoint at $1.525 billion. If you add in -- and that did not include any DPP [indiscernible] Tennessee -- add in, call it, $140 million of DPP monies from Tennessee and New Mexico, back out, call it, $20 million to $25 million from the divestiture of Cedar Park roughly $70 million, which is probably the miss in the second quarter and then the remainder being kind of revisions to the back half of the year based off of our previous expectations to get us to our new guide of $1.5 billion at the midpoint.

Got you. And then just a follow-up on some of the mix trends you're seeing. I know that payer mix has been a topic of discussion in recent quarters. I was just wondering if you could walk through the components of payer mix trend you're seeing and then Medicare Advantage, in particular, the type of growth you're seeing there.

Sure. The biggest declines we had were in surgical. And about half of those surgical declines were orthopedics. Most of the declines were primarily commercial Blue Cross business. So that's where we're seeing the biggest headwinds, which certainly impacted our net revenue per adjusted admission, impacted the flow-through to EBITDA and also lends us to believe that the consumer confidence and impact on household incomes and how people are spending their money, making decisions in health care is really the true reason for some of the headwind on surgical and care delivery at this point. It's those patients who have the highest co-pays and deductibles that are being most impacted. And I think even if you look at some other industry across the country where we're seeing consumers not spending money, their discretionary income on things. So again, that's the biggest decline. In terms of the exchange business, overall volume of exchange business was up, but acuity of exchange business was severely down with the biggest component of that being surgeries of exchange patients. So there, again, led us to the same conclusion because most of the exchange contracts have some higher co-pays and deductibles.

Congratulations to Tim on retirement and to Kevin and Jason on the appointments.

Thanks Ben.

The next question will come from Jason Cassorla with Guggenheim.

Great. Best of luck, Tim, in your retirement and congrats, Kevin. Maybe I just want to start on leverage. You've got some cash coming in, in the second half. You've done some refinancing activity earlier this year, but are there other areas you're hoping to refinance at this point, maybe drive some incremental interest cost savings, whether debt takeout or otherwise? And kind of just a follow-up to that, you're still about a little less than 1.5 turns away from your below 5.5x leverage target, maybe only a turn when factoring the back half of cash generation, incoming proceeds and payments. But perhaps can you just walk us through the remaining building blocks that get you toward that below 5.5 target at this point?

Thank you. Yes, happy to walk through that. So right now, as we look at our debt stack, we've got some 2027s -- $1.750 billion of 2027 that are our next current maturity. Those become current in March of 2026. And we've been pretty diligent over the years of trying to -- or disciplined, I should say, maybe over the years of trying to make sure we take care of those debts and not get too close to things becoming current. So that's top of our list of things we want to get handled and get that debt pushed out. Now that debt currently has a coupon of 5% and 5.8%, probably a little bit lower than the market is going to absorb right now, and we'll see a little bit of additional interest expense from that. But as we continue to make progress on some divestitures and chipping away other pieces of debt, we'll have an opportunity to offset any of those interest expense increases from the rate and continue to lower our leverage. As we look out in the nearest term over the next couple of quarters, as I mentioned, we've got the proceeds coming in from the Labcorp sale, which is almost $200 million and we have the contingent payment from the sale of Tennova Cleveland, which we should -- that's in the area of $100 million. So we should be getting approximately $300 million coming in, in the back half of this year. And then we're continuing to pursue some additional divestiture opportunities. There's a number of transactions that are in various stages. We're still getting some inbound interest, and we'll continue to look at that to manage our portfolio, not only where we believed we have the best opportunities to invest and to grow, but then also with some opportunities to maybe divest -- put that money to other use, whether that's directly paying down debt or investing in some growth opportunities, both of which would help us delever. I think we've given that a goal of below 5.5x by 2027. So we've got a little bit of time, although time is clicking away here -- ticking away. But I would go back and if you track our leverage over the last 2 years, we have consistently been bringing it down over a 2- year period. I'm fully confident we'll continue to make progress there and get to our goal.

Got it. Okay. Helpful. And maybe just as a follow-up, on the heels of the Labcorp deal, obviously, a nice cash flow -- cash inflow there. But maybe are there other opportunities for the enterprise that you're either evaluating to maybe outsource or maybe other non- core assets that you could look to offload that could drive that incremental cash or even EBITDA benefits at this point?

Great question. We continue to look at our business, seeing where we can make little tweaks similar to what we did. Our outpatient reference lab business is something that was not a core competency. And I actually believe that by completing this deal with Labcorp, we're going to provide a better experience for our physicians and also potentially get some savings to the company. We'll be using Labcorp almost exclusively for our reference lab and outsource business, and we'll be getting better pricing where we had been using them sporadically in the past or other outsource services, we can move that to Labcorp at a better pricing going forward. But we continuously looked at our business, I don't know that we have anything currently in flight that I would call out as being something that we could monetize. There are areas of our business that we consider as we grow and invest and develop that may be sources of revenue for us in the future. And those are something that we're looking at and which could be margin accretive if we were to decide to do that or get to a point where we think it's viable that we could sell some services.

The next question will come from Andrew Mok with Barclays.

I want to follow up on volumes because I'm having a hard time reconciling the lower volumes that you're calling out with some of the call-outs of accelerating cost trends from payers. Was there anything else you saw impacting volume trends beyond consumer confidence that might be more regional specific or anything on the policy front that you suspect is driving a hesitation to use the health care system?

Maybe the only other item I might call out, and it is admittedly difficult when patients don't come to our system to know exactly why they aren't coming and who those patients are when they're not showing up. But the other item that I would call out would be immigration. And certainly, in some of our markets that may have larger concentrations of the immigrant community in states like Arizona and Texas, possibly even Florida. There have been well-documented instances of individuals in the immigrant community not participating in some normal everyday things, not going to church, school, or going to the hospital, not going to concerts, doing things like that. I know the hospitals are no longer considered a sanctuary location, and there is concern even among immigrants with legal status that there's some fear in that community. That's likely caused at least in some of our markets, some softness in the volumes.

Great. Maybe just as a quick follow-up. I appreciate all the color on the estimated impact of state-directed payments. Is there any way you can share thoughts for how the expiration of enhanced subsidies might impact your business next year?

That was difficult to quantify in any real way. So I can say what we're doing relative to that is investing in some -- with our lobbying efforts in Washington and continue to work on that from a legislative standpoint. But in terms of quantifying, no, we don't have an estimate at this point.

The next question will come from Stephen Baxter with Wells Fargo.

I just wanted to kind of continue the guidance bridge conversation just to make sure that we understand kind of how you're carrying things forward. So I think the items you're flagging is the $70 million underperformance on a core basis during the quarter, the $25 million for Cedar Hill. Did you give us the all-in increase to Medicaid supplemental program expectations? I think there's more than just $100 million to -- maybe $120 million that you kind of let on before. I'm just trying to really understand as we think about the back half of the year relative to the $70 million underperformance, I guess how much of that are you carrying through into this guidance revisions that you made?

Thanks, Stephen. Yes, let me give you some more clarity on those state-directed payment programs. And sorry, if I did not make that clear. So we had previously indicated $100 million to $125 million of state-directed payment possibility as there is an annual run rate for Tennessee and New Mexico. That was just a 12-month run rate for each of -- or for the combined 2 states. In the second quarter, we actually picked up a retroactive piece back to 2024 for Tennessee plus 6 months of Tennessee and 6 months of New Mexico. So for the full year 2025, those 2 states will be about $140 million. That's the amount we're putting in our guide kind of just the midpoint for the DPP program. So that's the addition starting -- again, I'll run through it quickly, $1.525 billion at the midpoint was a starting point. We added $140 million. That's the $100 million to $125 million run rate plus the retroactive piece. Then taking out $20 to $25 for Cedar Park, taking out the second quarter miss and then adjusting our expectations in the back half of the year slightly.

Okay. Got it. And just it's really helpful to have these -- the sizing around the impacts from the bill. Is there an absolute number you can give us for what the current annual run rate of these programs are, so not including any of the out-of-period stuff, but just so we can maybe contextualize this as a percentage decline, that would also be, I think, pretty helpful to people.

No, I don't have that number exactly. We really look at those state-directed payment programs, once they're in place, they become part of the normal Medicaid reimbursement strategy for that state and normal Medicaid kind of reimbursement process. Those programs oftentimes have many different variations within a state, both at the district level, county level and state level. States then make decisions about increasing their rates or increasing the programs at various stages once they're in place. So we don't really call those out separately because they -- again, once in place, they kind of move more as an aggregate number within the state versus each individual program being on its own.

Got it. Okay. And maybe just one more, if I can squeeze it in. Just could you talk a little bit -- I know a lot of this, you think, is driven on the volume side by the consumer confidence changes kind of in the early part of this year. Are you seeing any kind of volume change in the Medicare part of your business, given that obviously, it seems like there would generally be less economic sensitivity there. I'd be curious just kind of your comment on Medicare specific trends, if possible.

Yes. We haven't seen much change in the Medicare book of business. And interestingly, the Medicare book of business has the lowest deductible component. So that is the group of patients least impacted, I think, by some of this consumer confidence issue. I think that really further supports maybe our belief that what's driving some of the patient behavior is around financial decisions. And so those patients are government-insured patients that don't have high co-pays and deductibles, haven't really changed their behavior in terms of coming to receive health care.

The next question will come from Josh Raskin with Nephron Research.

I'll congratulate Tim as well and Kevin and Jason as well. I want to go back to the difference in trends that you guys are seeing from the volume perspective relative to some of the hospital peers and certainly relative to the commentary from the payers, and I appreciate the commentary you've made. But do you think there's any difference from whether it's geographies or lines of business or outpatient networks that could explain that? Do you think others are embracing more technology or AI on the RCM side? Do you think any of that could be contributing to this?

There could be some differential in terms of location, types of markets, urban versus nonurban type markets. It's hard to say exactly. Again, I would point to when patients don't show up, it's very hard to necessarily know why or to track that. But I do think the differential between urban markets and nonurban markets could be part of that. In terms of difference between what we're experiencing and the payers experiencing, much of their cost increases could be coming from pharmaceutical side, maybe behavioral business, not necessarily a change in acute -- payments to the acute providers. I think their headwinds really are probably somewhere else. And otherwise, I can't really reconcile to them. Tim, I don't know if there's something you might want to add on this.

Yes, Josh, thanks for the question. I'll add on to the payer answer. I think the other area where I'm not going to say it's an outsized impact, but we've been speaking for several quarters on our investment in physician adviser services and really honing in on what we believe we should be getting appropriate reimbursement for care and services delivered. We have not seen an increase in our downgrades and denials as a percentage of net because of those efforts. And I hope it means we're keeping more of the rightfully earned dollars coming into our pockets versus into the payers' pockets. So that's one element I would throw in there. I don't think it's material, but we have not allowed that slippage to continue, which we said we'd be fixated on as a strategy for the company. In terms of your other question regarding strategy and/or technology and AI, that has also been a core strategy for CHS. I believe I mentioned last quarter, our investment in growth in robotic surgery platforms, we continue to see really strong growth in our robotic-assisted surgeries in the company. So I don't think it's due to any underinvestment into emerging technologies or services in our communities. In terms of the AI component, one of the things I'm really proud of is our investments into the development of a strong data science group here at CHS. We have some of the leading industry experts on supporting our efforts. We have deeper insights into the business as a result of that. And I'd also layer on the investment into the ERP, the enterprise resource planning tools. Again, we're, I think, in the early innings of that investment, but the insights that's gleaning into our business and our operations and our opportunities, I think it will be a really strong benefit and tailwind to the company for many quarters and years to come. So I don't think there's really anything in terms of where we maybe missed it strategically. I think it really is a lull in consumer confidence as we've called out. And as I said in my prepared remarks, I can't remember a time in this industry where the consumer hasn't come back. We still believe we provide absolutely essential services to the communities we serve.

Great. Great. That all makes sense. Just a quick follow-up on the Labcorp. Were your reference labs, was that -- were those assets EBITDA positive for you in the past? And then is it conceivable that having Labcorp take care of those assets is actually additive to EBITDA?

We don't have an exact measure because it wasn't a business that we ran separately, but certainly, we've done a fair amount of work before making the decision to sell that part of our business. As I mentioned, it was not a core competency of ours. It may have been marginally EBITDA -- or there may have been some marginal EBITDA generation from that relatively small. And I think that, again, overall, getting some cash upfront and providing a much better experience for our physicians will be much more beneficial to our practices and ultimately to our EBITDA going forward. Also keep in mind that -- even our employee physicians did not use our in-house outreach lab business exclusively. We were still sending portions of our business out to Labcorp to Quest to other third-party labs. So we really have now an opportunity to partner with Labcorp on this and bring just a better solution with their technology, and it is their core competency, and they'll be able to deliver those services at a cost cheaper than we could provide them ourselves.

The next question is a follow-up from Ben Hendrix with RBC.

Great, thank you very much for squeezing me in here with one more. I just -- we've gotten a lot of questions on the rural health transformation program and the $50 billion allocated under the OBBB Act. Any way to frame kind of your contribution there to what extent you're including those funds in your outlook? And how do we frame kind of what the benefit could be even if just an assessment of how much of your program would be eligible for those -- for that program?

Great question, Ben, and one we've received a couple of times already and one we're thinking about quite a bit. Again, we're investing in lobbying efforts around that. There is no clear answer at this point as to how that money is going to be spent or divvied up amongst the rural health providers. So that's all yet to be determined. I believe my understanding is 50% of that will be at the discretion of CMS and the other 50% given to the states to determine and even they may determine differently in each state, how they distribute the money. So a lot more to come. I also understand that there's been a proposed bill in the Senate to increase the amount from $50 billion to $100 billion. So that is still yet to come. As we look at our portfolio of hospitals, I would say roughly 40% of our beds, we believe would qualify in terms of a definition of rule. But even that isn't entirely clear because throughout the medical regulations in CMS, there's multiple definitions of what is rule. And I'm not sure which is the exact one that will apply here. We're giving our best estimate that is about 40% of our beds.

This concludes our question-and-answer session. I would like to turn the conference back over to Mr. Tim Hingtgen, Chief Executive Officer, for any closing remarks. Please go ahead, sir.

Great. Thanks, Chuck, and thank you, everyone, for joining the call today. I want to close by thanking the amazing people who work across the CHS organization for the opportunity to serve as their CEO and to support their commitment to provide quality compassionate care for all of their patients. And I want to say once again that I'm grateful to be passing the torch to Kevin Hammons because he's a capable and committed leader for CHS. I look forward to all of the good things ahead for Community Health Systems. If you have any additional questions, you can always reach us at (615) 465-7000. Have a great day, everyone.