Good afternoon, and welcome to the Surgery Partners, Inc. First Quarter 2020 Earnings Call. [Operator Instructions] I would now like to turn the conference over to Tom Cowhey, Chief Financial Officer. Please go ahead..

Good afternoon. And welcome to Surgery partners first quarter 2020 earnings call. This is Tom Cowhey Chief Financial Officer. Joining me today are Wayne DeVeydt, Surgery Partners' Executive Chairman; and Eric Evans, Surgery Partners' Chief Executive Officer. As a reminder, during this call, we will make forward-looking statements.

Risk factors that may impact those statements and could cause actual future results to differ materially from currently projected results are described in this afternoon's press release and the reports we file with the SEC. The company does not undertake any duty to update such forward-looking statements.

Additionally, during today's call, the company will discuss certain non-GAAP measures, which we believe can be useful in evaluating our performance. The information presentation of this additional not be considered in isolation, or as a substitute for results prepared in accordance with GAAP.

A reconciliation of these measures can be found in reconciliation of these measures can be found in our earnings release, which is posted on our website at surgerypartners.com, and in our most recent quarterly report when filed. With that, I'll turn the call over to Wayne.

Wayne?.

Thank you, Tom. Good afternoon, and thank you all for joining us today. I want to start today by recognizing the crisis facing our nation. The COVID-19 pandemic literally impacts all of us as nothing else in our recent history has. And we hope that this nothing else in our recent history has. And we hope day finds you and your love ones safe and healthy.

This crisis has also shown us our collective strength. I'm continually humbled by the dedication of our emanations frontline workers, doctors, and particularly our nurses and medical staff, who are fighting the steadily disease each and every day and saving lives. Thank you.

While the COVID-19 pandemic has presented us unique challenges for Surgery Partners, it is a testament to the strength of the team we built over the last two years to see how quickly and effectively they responded to the task. We started the quarter with two months that saw same-store revenues and adjusted EBITDA grow at nearly a double-digit rate.

March was also off to a strong start. Before COVID-19 began its exponential spread, we saw volumes drop by nearly 75% as some of our facilities reduced operations to a day or two per week, serving only the most critical patients.

Our team quickly mobilized to the task at hand, reducing facility level overhead, slowing capital distributions, while tightly managing working capital. Eric will talk about our actions in greater detail. But know that this team reacted swiftly, decisively and responsibly to preserve our business and liquidity.

To further enhance our liquidity in this uncertain environment, on April 22, we closed an incremental term loan raise that, when combined with assistance from government programs, should give us ample expenditures and from government programs, should give us ample availability to weather this storm.

Tom will speak to our liquidity efforts and position in more detail. But our ability to execute a financing transaction in this market, that was transaction in this market, that was 13 times oversubscribed, speaks to the power of our business model and the execution of our teams. Strategically, we've never felt stronger.

Surgeries are back on the rise, PPE availability is increasing, states are lifting restrictions, and we are beginning the process of ramping our operations back up after the pause in operations our facilities experienced for the last several weeks.

Further, this crisis has demonstrated the power of our short-stay surgical model to the healthcare ecosystem. demonstrated the power of our short-stay surgical Now more than the value, convenience and safety of our facilities. Our physician recruiting efforts in March and April have yielded strong results. Our pipeline of M&A and results.

Our pipeline of M&A and partnership activity remains robust. ever, patients, providers and payors recognize partnership activity remains robust.

Stand-alone facilities have a new appreciation of the benefits of being part of a larger organization, and we are looking forward, over time, to return and potential acceleration of our previous growth trajectory. With that, let me turn the call over to Eric to talk about the company's operations.

Eric?.

first, ensuring that our facilities are safe places to conduct procedures. We are strictly following CDC guidelines as well as screening patients, visitors and our colleagues to ensure compliance. Our facilities follow stringent cleaning policies, which have been further enhanced in focus and frequency.

And most only see prescreen patients by appointment, which helps to reduce our overall risk profile, making our facilities highly attractive options in this environment. options in this environment. Second, and closely tied to our first principle, we are focused on ensuring appropriate use in quantity of PPE.

Our teams have been hard at COVID-19 since January. Given the importance of Wuhan and the work thinking about the supply chain implications of about the supply chain implications of work thinking of disposable of disposable medical equipment.

Our procurement teams have done an exceptional job this year, proactively managing our supply and actively securing alternate supply on the spot market, while appropriate use and the spot market, while appropriate use and conservation of PPE remains a focus of our entire team, our channel checks indicate that some of the most difficult checks indicate that some of the most difficult items defined, like masks, should become much more items defined, like masks, should become much more widely available over the next few weeks.

While demand for critical items remains higher than ever, we believe we have sufficient inventory to reopen and to ramp up our operations. Finally, we have been focused on managing our costs to scale them appropriately with volumes.

It will take time to get back take time to get back to traditional levels of operation, and we are committed to adding staff and cost back into the system in cost back into the system in a very responsible responsible manner and commensurate to revenue. One final thought. Our recruiting teams have never been busier.

In the first three months of this year, we recruited nearly as many new doctors as we did in the COVID-19 fundamentally changed the way that patients and surgeons will think about the role that the role that play in healthcare delivery.

We also believe that scaled independent operators, such as Surgery Partners, will be uniquely the first quarter of 2019 despite crisis. We believe that this crisis has that. I'll turn the call over to Tom, who will provide additional color on our financial results.

Tom?.

the social security payroll match, The Cares Act provides for the provides for the deferral of the social security payroll tax match, which will be deferred for the remainder of 2020. The company expects that this will result in not having to fund approximately $15 million to $20 to $20 million of taxes in 2020.

Half of this amount will have to be paid in December 2021 and the other half in December of 2022. CMS direct grants. As part of its efforts to distribute Cares Act funds, starting on April 10, 2020, Surgery Partners 2020, Surgery Partners facilities received approximately $45 million of grants.

Our current view is that these grants will be recorded as revenue in the second quarter of 2020. Medicare Advanced payment program. The company also received approximately $120 million of accelerated payments prior to April 26 when CMS subtended this program. Per the terms program.

Per the terms of the program, we expect to start repayment 120 days from receipt of funds, and we project that the vast majority of our advanced payments will be settled this calendar year. payments will be settled this calendar year.

The company's ratio of total net debt-to-EBITDA at the end of the first quarter of 2019, as calculated end of the first quarter of 2019, as calculated under the company's credit agreement, was up slightly at approximately 7.3 times, primarily as a result of modestly higher net debt at March 31 and lower trailing 12-month adjusted EBITDA in the current quarter.

quarter. structure, with no financial covenant on the term loan or our senior unsecured notes.

Importantly, as part of the incremental term loan rate in April 2020, we the company's lenders, under its revolving credit facility, waived our leverage covenant on that facility for the remainder of 2020 and provided substantial flexibility for the calculation in 2021. Moving on to our 2020 outlook.

As you know, on substantial flexibility for the calculation in 2021. March 23, due to the evolving unpredictable and unprecedented nature of the COVID-19 pandemic on the global economy and our business, the company withdrew its full year 2020 outlook.

While we remain optimistic that the month of May could bring materially higher volumes than we experienced in the back half of March or April. The company is not providing an updated outlook at this time. We expect to be in a better position to provide an update to investors when we report June results later this year.

In summary, while Surgery Partners has had a strong start to the year, the Corona virus pandemic has impacted our business across the country.

Through quick and decisive actions, our team has hopefully proven to investors that we are prudent stewards of your capital, and we bring that same level of diligence and focus as we reopen and prepare for the new opportunities that, we believe, will be the new opportunities that, we believe, will be crisis. With that, we will open the call for Q&A.

Operator?.

[Operator Instructions] Our first question comes from Kevin Fishbeck with Bank of America. Please go ahead..

Kevin. Thanks for the question. First, let me just for all those participating, we appreciate you being here. We recognize that this is a little bit unusual, and that all of us are honoring the stay in shelter orders and doesn't allow us to be face-to-face during this period as even a management team.

But that being said, let me start by saying that we feel very fortunate there, Kevin, in that. Obviously, these were not procedures that we were waiting to come to us, but rather many of these were procedures that, obviously, we've already rescheduled. We've been working with our surgeon partners.

And as we started to shut down facilities, And as we started to shut down facilities, honoring the state and federal requests that came with that, we were regularly reaching out to those patients to find the right time when we patients to find the right time when we would start to reschedule.

So with that, I'm going to ask Eric to comment in a little more granularity. And can give you some color commentary around how things are actually ramping up..

Yes, Kevin, thanks for the question. A couple of things I would say. We're obviously, we're guardedly optimistic. There's a lot we don't know about the pandemic, and a lot of things could change. It's incredibly different by geography. But in general, we are very, very pleased with the amount of momentum we have in scheduling.

So early returns show a significant uptick week after week. And so I would say this, that I don't want to get into giving you a specific percentage just because there you a specific percentage just because there are so many unknowns with how the pandemic will go, what will happen in a local market, how physicians react.

I will tell you, in general, our physicians are I will tell you, in general, our physicians are anxious to get back to work. So far, our patients have been very open to coming back for procedures. We have facilities that are ramping up slower, and we have facilities that are already back to budget.

And so giving you a percentage would be too early at this point. That's the reason we pulled guidance, but we're certainly pleased with the this point. That's the reason we pulled guidance, early results as markets start to open up..

All right. Well, then, I guess, when we think about the volumes coming back, I guess, at some the volumes coming back, I guess, at some point, this should get back to normal.

And then do you believe that there will be pent-up demand that we could see potential periods of above-average volume? And if so, either way, are there gating factors to that volume coming back? And do you have enough extra excess capacity, do you have an FDP, is there enough physician outwards in the day to get everything kind of back? And how do you think about those types of gating factors?.

Kevin, this is Wayne. A couple of interesting comments. I'm going to ask Eric to elaborate in just a moment. But first and foremost, I think as you already almost back to normal, which is a moment. But first and foremost, I think as you are behind that. And so I think at what pace we'll get back to normal. We've been at what pace we'll get back to normal.

We've been belief that we could get to capacity maybe sooner a little bit surprising at Phase, but obviously, several the question becomes, well, what if there's excess demand? I would tell you, first and foremost, that I do think there are many reasons we could get additional incremental demand as the year progresses. Emphasis added there.

And that's because of what we've seen on the physician recruiting front. And I'm going to let Eric elaborate on that in just a moment. The other thing that I would highlight is around capacity. That is not necessarily a concern for us. If you remember, we typically run normal hours Monday through Friday. We don't typically run past six p.m.

It wouldn't take don't typically run past six p.m. It wouldn't take much for us to open a few more hours each day. We're typically not open on Saturdays and Sundays. As you saw at year-end last year, we can flex up and down and actually open up on Saturdays and Sundays.

So the ability to add anywhere from 25% to 40% additional capacity is very much additional capacity is very much available to us if the opportunity presents itself. But I'm going to ask Eric to elaborate a little bit on the physician recruiting. So I think it's really relevant of what we're seeing right now in this environment.

we're seeing right now in this environment. And I Eric should comment on PPE because, I also think, think, that was a significant gating factor that we said was an issue when our country was first impacted by this. And you can kind of tell you where that stands today, and whether we think it will impact us going forward.

Eric?.

Yes, Kevin. So as we go in a little bit more detail. Certainly, I would just concur with Wayne's comments. As far as capacity goes, we feel very comfortable with our ability to flex up. And we certainly know that there is a backlog, right? So we have a number of cases that will need to be done.

And the question by market, of course, is how fast those will get rescheduled? We're encouraged early on. And there certainly is a possibility we could on. And there certainly is a possibility we could end up with, I think, excess demand. There's some question, though, obviously, primary care is getting back up to speed.

There's a lot of questions around just consumer behavior. But early indications would say, there's a real chance for that. say, there's a real chance for that.

And I would just say big picture, net-net, we feel coming out of just say big picture, net-net, we feel coming out of and coming out of the closure period, we are net-net better positioned for growth than we were before. So high level, longer term, we feel like very, very bullish on the business.

There's a lot of questions of questions around just how fast it comes back, and we're certainly encouraged by early signs. To go to Wayne's point, from a physician recruitment standpoint, it's notable that we were close to having the same number of new physicians even with the pandemic hitting. And we've been really impressed, too.

I mean, the physicians we've added this year have been significantly higher producers and higher net revenue. And so we continue to be very, very successful in our focused physician recruitment.

And that's not only on our traditional path, but in the time of this closure or slowdown, we've had a lot of physicians in markets that have reached out to us or that we've made contact with that are newly interested in having outpatient facility that's focused on these procedures. So I would say my outlook is very, very positive.

The timing is hard to know because of consumer behavior. We know that there's a pent-up or backlog of patients that we're going to be scheduling. We don't scheduling. We don't know how fast new patients will return, although early signs are very positive.

And to add to that, and I think Wayne's major point is, we do see real upside in physicians who have a backlog who maybe can't get into their hospital that they're used to going to or maybe want a different location-based on patient request or their location-based on patient request or their own comfort that's really just focused on doing outpatient surgery, which our facilities, obviously, are very, very specifically focused on doing just that.

So overall, very, very optimistic longer term. In the short term, there's still a lot of unknowns that that we have to manage through..

And then maybe just last question. As part that longer-term growth rate, how do you guys think about the impact of a recession? It seems like we're heading into one that may last for some time.

So how do you think about the impact on volumes and payor mix and if there's any offsetting cost items?.

Kevin, thanks for the last question there. Let me first just start to remind folks that if you were to look at history, in previous recessions, and I would take you back to 2008 and 2009.

It's important to recognize that what you would have thought would have intuitively been a behavior, which is where to take you back that that people would really hunker down and postpone elective procedures. And we actually saw just the opposite.

In fact, you can go back and look at how successful the providers who were in those early years of the recession and how much of an impact managed care companies took.

And part of the reason is that what happens is that many individuals recognize recognize that they had COBRA coverage, and they recognized that if they were going to be laid off for an extended period of time, this was actually was actually a more opportune time to get those elective procedures done when they could have more time to recover.

And to do it while they still had coverage being provided by their employer. And so that's one dynamic that we believe, could still play out.

The second concept I would make, and some people may question would say, well, aren't deductible higher today than they were back then? But the answer is today than they were back then? But the answer is not necessarily the case. In fact, in many cases, CDHP had already worked its way through the system.

And so and many employers have actually incentivized employees to go to lower cost settings cost settings by waiving deductibles. So if anything, I would call it net neutral and looking at deductibles from back then versus today. So I think from then versus today.

So I think from our perspective, we view this as an opportunity to ramp up rather than ramp down in the recession.

And then I would also simply add that because we're very focused on higher acuity cases, and as you know, Medicare has environment, and hits are now in the in the HOPD setting, and we now moved TKAs to our now moved TKAs to our view that to be the next round, one of the following year, I think we're really well positioned as well for the growth in Medicare, which is kind of a new piece of ply for our business model.

So I don't want to minimize that there could be impacts with the unemployment. But I would also say, I think we're well positioned based on history and based on the new expansion that we're we're the outpatient setting for Medicare..

Yes. Wayne, the only thing I'd add there is I just say, our ASC say, our ASC cost model is able to, in many cases, take on incremental government patients, especially of higher acuity and actually drive a nice margin. hospitals to do, and that number obviously represents the savings versus the acute care hospital.

So we feel like the government payers hospitals to do, and that number obviously represents the savings versus the acute care hospital. So we feel like the government payers shift, obviously, it's not a positive. But as incremental business, it certainly is helpful.

And then on the payor side, look, it will be interesting to see how payors react coming out of this. We've already seen a few payors that have become more active and aggressive on actually creating professional fee increases to do cases in the appropriate care setting. So we think there's some offsets there.

The one thing I wanted to go back to that I didn't mention that Wayne asked me, too. On the PPE, Kevin, one of the big reasons that elective surgeries were shut down early on was really this surgeries were shut down early on was idea around keeping capacity to deal with the surge of COVID patients.

And I think as that settles down and as we restock our PPE shortfalls in inventories, we don't see a reason, even if COVID were to come very good results even with the outbreak. And so my very good results even with the outbreak.

And so my at one point, I think it's really important for everyone to understand is if we have enough PPE, I don't see a reason, even if there were an increase again in COVID cases, for us to not be able to stay open and provide great healthcare to patients..

Our next question comes from Brian Tam Tanquilut with Jefferies. Please go ahead..

Okay. Good afternoon. I hope you guys are all doing well. I guess, my first question for Eric or for Wayne. As I think about the healthcare system exiting COVID, how are you thinking about the shift of procedures from hospitals to well. I guess, my first question for Eric or for Wayne.

As I think about the healthcare system exiting COVID, how are you thinking about the shift you guys? I mean, of procedures from hospitals to the hospitals are, obviously, also dealing with re-ramping.

Should we do you guys think that we're going to see more doctors saying, "I'll do more procedures in the ASC setting rather than the hospital since there's hospital since there's still COVID risk still COVID risk there or for whatever reason?".

I'm going to let Eric elaborate on this because we've had some pretty interesting experiences. Let me just highlight a couple of things to keep in mind.

We've actually got a few of our facilities now with these hospitals about walls that have been licensed now to perform certain hospital procedures, which, we think, is an interesting dynamic in the environment. Two is, the physician preferences are going to be very relevant.

And more importantly, more importantly, their preferences are being driven by their patients their preferences are being driven by their patients and how they feel about going to an environment where you could still have a ER actively bringing in COVID patients.

So it's been an interesting dynamic to see both how our surgeons feel now in this new environment, helped with how their patients feel.

So Eric, maybe you want to elaborate on some Eric, maybe you want to elaborate on some of our experiences in our different markets?.

Sure. Yes.

And I guess I'd start off with, net-net, obviously, we don't think this in no way hurts the transition of patients from hospitals, and we do think, over time, the impact of the shutdown and just people focused on their health and wanting to be as cautious as they can about exposure, we think we're well positioned, just given that we're focused on simply providing surgery, and we can do some things from just an access and control standpoint that's hard for that's hard for larger settings.

So I think that's certainly a good thing. I would say, across our markets, we have seen some early indications. We've got some physicians who, in the past, had not been interested in ASCs, that have become more interested.

We have current physicians who, due to the situation are bringing higher acuity patients to our ASCs with good results, and I think patients to our ASCs with good results, and I think that certainly opens the door for us to continue to do that and make the case that there's more and more stuff we can do safely in our ASCs.

So net-net, I never want to bet on consumer behavior, especially in the short term. I would tell you that I don't think there's anything that's happened, that would make that would slow down the transition. I do think probably, net-net, it's going to pick up the transition when it comes to both consumers and physicians.

Early indications would point to that. the impacts on our business. but we are optimistic about things that could happen over the next coming weeks,.

I appreciate that. And then I guess, Wayne, more strategically, you obviously loaded up the balance sheet with more debt, prudent move in this environment. But how are you thinking environment.

But how are you thinking about future cash flows given the debt load? Are we at that level where, basically, most of your cash will be sucked up by the interest expense going forward?.

Brian, thanks for the question on this one. Look, much cash on this balance sheet as we could first and foremost, our priority was to prudently possibly do. And I'm possibly do. And I'm going to have Tom comment in a moment. Just so everyone knows the kind of cash flow we have. Because what we didn't know is whether or we have.

Because what we didn't know is whether or not this would be incredibly prolonged. And we still don't know today. We think we should prepare for that. But I do want to remind everybody that, while we're very optimistic about what we're seeing in May in May already, we are still in the early innings, and we should all just keep that in mind.

But that being said, look, I think long term, we were always planning to delever through growth, but we knew term, we were always planning to delever through growth, but we knew to really become offensive at some point.

And we believe we were in a position right before the believe we were in a position right before the pandemic to move on the offense.

We believe we are in the position to be even more offensive now, so in the position to be even more offensive now, so we make even more opportunities will present themselves that we will have to be thinking about other means and mechanisms to bring capital in the organization that will allow us to really put to work this chassis that we built.

And so we recognize the leverage is a concern right the leverage is a concern right now, but we want everybody to be aware that, that now, but we want everybody to be aware that, that cash we borrowed right now is sitting there and can easily be paid back down if we think things normalize sooner than later, or can be deployed aggressively for M&A because we aggressively for M&A because we have a robust pipeline, of which much is under LOI, but we have hit the pause button on that and not closed any of those until we see how this progresses.

With that, Tom, maybe you might want to highlight a little bit about our cash position so people understand both our ability to pay down existing debt if we so chose, or to put it on the offensive at multiples that are below our current leverage. leverage..

Sure, Wayne, I would be happy to do that. We don't lot of flexibility, but it's we're prudent right now. We're being cautious. We'd like to make sure that what the shoots we're seeing in May are going to continue to grow, and we're going to see the business continue on a nice trajectory business continue on a nice trajectory to recovery.

the line the line that we were previously on. But we believe believe that this that this business, if anything, is strategically stronger business, if anything, is strategically stronger over the long run than it was before this crisis, on the other end of this crisis. And as you think about the other end of this crisis.

And as you think about our goal of growing adjusted our goal of growing adjusted EBITDA by double-digit rates, really what you're talking about in rates, really what you're talking about in terms of interest expense, should we leave that capital leave that capital outstanding past the 1-year mark, would be really four outstanding past the 1-year mark, would be really four to six months worth of pushback on kind of your breakeven point.

So there's a it's I think it was a calculated move to really help our overall liquidity position. We think of it as an insurance policy. And it gives us a lot of option value as we value as we think about how we might want to go on offense on the other side of this crisis..

Do totally agree. I definitely understand the prudence of that. But I guess, last question related to those comments you made. How should we be thinking about modeling the cost structure at this point? I know you've had adjustments with the wages and all the other operating costs. So the other operating costs.

So as I think as I think about second quarter, going forward, if you mind just helping us think through modeling the cost structure?.

Yes. I'm going to ask Tom to comment on this in some details.

The one thing I want to remind all of our listeners is that our model was so unique that if listeners is that our model was so unique that if you think about variable cost being around 40%, we took that out right out of the gate, and we actually then flat fixed costs, which is highly unusual, but we flexed down, right? We asked our executives to take substantial pay cuts across the board.

We took other fixed costs out of the system. And we did it with an intentional bias that we thought it was the prudent thing to do in this environment. But we did of the system. And we did it also knowing we had to be able to flex up quickly if things begin to ramp up again very quickly.

And so as you've heard from Eric early on, we are seeing positive momentum. But I would on, we are seeing positive momentum. But I would anticipate that we would flex up slower even with the momentum then we flex down. I mean, flex down, then we flex down. I mean, flex down, you had to take the actions aggressively and immediately.

And we started that in mid-March, but flexing up, I think we're going to continue to pull the variable cost as needed. But I think even some of those fixed costs, we're going to hold on for couple more months so we can see if things are actually improving at the level we expect and see them improving.

But with that, Tom, maybe you might want to highlight a little bit around some of the things that have been done, and how you feel about that timing?.

Yes.

I guess, as you think about the overall cost structure, and you look at some of the big line items on the P&L, there are some that are going to be variable in nature, supplies, which variable in nature, supplies, which is a very large portion of our expense; the medical and professional fees, as you look at those, those pretty naturally flex up and down with volumes.

There's some outside medical services in there, they're cleaning services medical services in there, they're cleaning services in there, there's there's a variety of different in there, there's there's a variety of different factors.

When you're only working a day or two a week, you aren't spending as much on some of those as possible as you might have been otherwise.

And then it really gets into what have you done with then it really gets into what have you done with your fixed costs? And I fixed costs? And I had a mentor who once said, " All costs are variable over the long run." And I think it's really just a question of how long is the long run. And for us, it was about for us, it was about two weeks.

We two weeks. We converted salaried converted salaried workers into hourly. We furloughed employees. We furloughed employees. We reduced corporate overhead. We reduced corporate salaries. We worked with lessors to get deferments.

And we gave you the range of as you think about the quarterly we gave you the fourth quarter, I think, we've got about $380 million $380 million worth of kind of cash expenses if you worth of kind of cash expenses if you look at the cost structure ex D&A.

And we're at, call it, 50% right now, 45% to 55% was the range we right now, 45% to 55% was the range we gave you in the 8-K in terms of where we thought we thought we had flexed had flexed down to on a cash burn for those operating expenses. operating expenses.

As we on the way back up, we've got to be cautious to let those back out, and our operators our operators are doing an outstanding job on this. They are pulling together ships in a way that is the most partners.

We are thinking about what the staffing levels are, and we're rethinking how we do certain things to try to take advantage of this really unique window to try to reimagine the way window to try to reimagine the way that we do that we do certain things.

And so it's hard to tell you exactly what it's going to look like on the way back up, only to say that we wanted to trail the volumes a only to say that we wanted to trail the volumes a little bit because we want to make sure that we don't have to do this again and take two steps forward and three steps back..

Our next question comes from Whit Mayo with UBS. Please go ahead..

Hey, thanks.

Good afternoon, Eric, I'm just trying to think from like a perioperative standpoint, can you talk a little bit about how cases are logistically working now? And I guess what I'm really getting at is, can you operate as efficiently on a per case basis? I think the answer is no, but just wondering how you're looking at case time throughput, turnover, any new processes or technology that you guys might need to look at to enhance productivity?.

Thanks for the question, it.

So yes, I mean, obviously, there's additional steps we're taking in the perioperative space, whether when it comes to the perioperative space, whether when it comes to cleaning between cases, the PPE that's required to be changed out between cases, we're thinking about be changed out between cases, we're thinking about air flow changes.

There's a lot of things that we're air flow changes. There's a lot of things that we're putting in place to make sure we keep our colleagues, physicians and patients safe.

With that said, I think within our setting, we have capacity, and we have physician patients right now, as you can imagine, they're pretty patient and understanding of what we're trying to get done. And understanding of what we're trying to get done.

And so we absolutely believe, while we will lose so we absolutely believe, while we will lose some efficiency, I don't think it's so monumental in many of these kind of shorter cases. And we definitely of shorter cases. And we definitely believe that we can work around those.

And part of the way we're doing that, too, is this downturn has given us a chance or this downtime has given us a chance to kind of reevaluate how we think about reevaluate how we think about block scheduling, work with our docs to change out change out the way we scheduled various cases on various days, and we've actually created, I think, some more capacity during this time with the way we'll do things going forward.

So net-net, yes, there's going to be a little bit of extra time on case turnaround. Some of that is managed in the ASC world when you're able to use a couple of rooms, when physicians are able to bounce a bit.

But I would just say, in general, we don't we do see it as it's going to slow us down on turnaround times as we don't think it's so significant that it's going to create any kind of true capacity issues for us, if that answers your question?.

Yes. No, that's really helpful. Maybe just a follow-up on Kevin's question for a second back just to the economic impact.

And you sort of alluded, Eric, to maybe looking at government Eric, to maybe looking at government business a little bit differently that historically hasn't been a payor that has been necessarily that attractive elaborate a little bit more on how you may be approaching this differently? you may be approaching this differently?.

Sure. So a couple of things I'd say there. So let's start with Medicare, I'll differentiate between Medicare and Medicaid. With Medicare, because we're doing higher acuity cases with Medicare patients, the reimbursement, given our cost structure on those cases, it tends to be OK for us. We can drive a margin whereas the hospitals might be negative.

And so and where you get the might be negative. And so and where you get the big benefit when you think about growing that Medicare share is when physicians bring those Medicare patients they tend to bring all their patients. They don't want to split their day. And patients. They don't want to split their day.

And so we see Medicare patients, in general, as a way for us to grow our overall business, while clearly not while clearly not as profitable as commercial patients. They are profitable for us. We're able to manage our cost profitable for us.

We're able to manage our cost structure in a way that a lot of hospital systems aren't going to be able to get there. And so aren't going to be able to get there. And so really good about that ability. And then on the Medicaid side, it's a state-by-state issue. Some states are pretty good on helping make that work.

And certainly, even with Medicaid, because of our cost savings, there's some room there to find to find ways to make that work. And it's again, state by state. There are some cases where or some states where Medicaid is really hard for us to figure out how to make work.

But I have a feeling, given the cost pressures, we're already as I mentioned earlier, we've seen some big blues across the country really take aggressive stance to raise professional fees for physicians who do cases in the ASC setting.

I think there's going to be opportunities for us to find whether it's shared opportunities for us to find whether it's shared savings, which we're doing with some payors across the country, or other models to actually make some of those cases work or in the past, maybe they weren't things we consider.

So I think it there's a lot yet to be seen, but I'm optimistic, given our structure versus the rest of the healthcare system, structure versus the rest of the healthcare system, that we can find ways to add that volume and make it work in our facilities..

Okay. Maybe just last one for me. I was really curious, Wayne and Tom, to get your perspective on just COBRA? just COBRA? And how you And how you think consumers may look at think consumers may look at COBRA? And COBRA? And I guess 30% of patients signed up for COBRA last go around was it's obviously a lot more expensive.

There's not a lot of premium support today.

So I'm just kind of curious how you guys think that COBRA may work out in this recessionary environment?.

Yes. Again, it will be interesting to see if what we saw back in '08 and '09 continues to play. I think like I said copra is always more expensive than what to the question is what alternatives are available to? And in many cases, to it's a better alternative than what is immediately available to them.

Now any folks will research and figure it out, but again, we know that the behaviors we saw last time with COBRA were uniquely different and that people actually did utilize it, did enroll and did get elective procedures that were postponed actually completed. I do think they are one of the actually completed.

I do think they are one of the more unique changes as well as if you go back almost you go back almost a decade, the shift to ASO has grown meaningfully in the shift to ASO has grown meaningfully in the last decade. It the last decade. It high-cost settings into high-cost settings into lower-cost incentive environment.

And so the comment I was making with earlier was that even if you model and assume there's some kind of a cost shift that's higher than higher than what it was 10 years ago.

I think that's true potentially on the premium side, clearly, maybe a bit on the deductible, it would most likely be offset, though, by the various incentive programs that have been built in the last decade to have people actually get the elective procedures done people actually get the elective procedures done because those end up being meaningfully less than what they would have experienced a decade ago.

So unknown environment, but history would say that people actually get procedures done, not stop them. And again, for what it's worth, one month in the month of May, at this point halfway through in the month of May, at this point halfway through when states are opening. But we are seeing volumes move up faster than we had anticipated.

And in when states are opening. But we are seeing volumes move up faster than we had anticipated. And in states that have been open for over a week or so, we've had a few of these already, where they're already getting to our original already getting to our original run rate budget.

So early indications would say behaviors would say people are going to go get these procedures done if they can get them done..

Yes. No, that's helpful.

And I guess, it's way too early from a revenue cycle perspective to think about collection changes, I presume that it's just too early, right? Tom?.

Yes. There's a couple of things that we're doing on that with, number one, just as we think about disruption to the payers' claims processing, we've been monitoring that very closely. And actually, we've been pleasantly surprised with what we've been seeing in from the AR. So that's been a positive.

On the self-pay side, we're actually looking at some new easy and as smooth a choice as possible for as many possible for as many consumers that want to get that care. We think that's really one of the things that could really be really be a differentiator moving forward a differentiator moving forward with some of those patients..

Our next question comes from Ralph Giacobbe with Citi. Please go ahead..

Thanks. Good afternoon. I may have missed it. Did you give April and, perhaps, first week of may trends? I know you said perhaps, first week of may trends? I know you said surgeries were sort of back on the rise.

Just hoping to get a little more quantification around sort of volume and revenue would be helpful as well?.

Ralph, we did not give specifics on April or May, but we'll try to give you some broad goalposts. Tom, please elaborate further if you think it's warranted.

But keep in mind, around mid-March is when the vast majority of our facilities were either mandated to be shut down or, because we were preserving PPE for the greater good of the country, we started to substantially reducing procedures.

And so, come mid-may, you can gauge what so, come mid-may, you can gauge what we did disclose, which is we think I'm sorry, mid-March, excuse me, relative. We thought it excuse me, relative.

We thought it was about they were down about 14,500 surgical procedures just due 14,500 surgical procedures just due to COVID in that kind of two week window toward the end of March, that was really kind of like door shutdown, very little activity. Happening. Those trends continued in April.

So I would tell you that it was pretty much what we saw in those last two weeks of March has been almost exactly for the entire month of April. That being said, as the country is reopening, it has already grown exponentially. And now it varies by state, very big facility. But the ramp-up, at this state, very big facility.

But the ramp-up, at this saw in volume in April. But keep in mind, April is volume in April. But keep in mind, April is very low.

And the question will be, will those trends, a few weeks into May, continue the back half of May? And then will, in fact, those continue into June as the rest of the economy opens? And those are the unknowns for us, which is why we really don't want to even comment on May at this point other than to say what we see scheduled so far and procedures that are either have in to date or starting to happen are running almost 2 times what we saw in April, but still low with how low April was.

Tom, anything else you want to elaborate on or Eric?.

No. And I think you covered it pretty well. The that what we saw in March was we said kind of kind of stabilized in April, and May looks like it's starting back up. You can see from actually, after I have got a wonderful website that kind of just talks about all the restrictions and when they're listing lifting.

And so a lot of our key geographies are opening back up. It's a function of how quickly they get back online and when the patients start coming in to see what that trajectory patients start coming in to see what that trajectory looks like.

And we'll have a better feel for that and it's, again, it's a market-by-market thing, we and it's, again, it's a market-by-market thing, we do continue to believe that we'll make progress month-over-month. Okay..

Great. That was part of my next question. Just more a little bit more on the demand side. So it sounds like, from a physician standpoint, not so much sort of apprehension from them.

Anything more on early conversations with patients sort of willing to come back now versus weight? And then any concern about this sort of early bolus from kind of pent-up demand and then, perhaps, a falloff because just the pipeline takes a while to fill? Or any other thoughts just around there in terms of some of that trajectory?.

Yes. That's probably the most difficult part, Ralph, right now, is that probably the best way for me to me to say it is, having seen April, I think we took a very cautious view that April would continue for May and June, and we took actions to reflect that it would continue for the entire quarter. Obviously, that continue for the entire quarter.

Obviously, that weeks into May. And so which is good. I mean we've taken the right actions to take cost out of the system. And obviously, we're seeing the system. And obviously, we're seeing cautious position is not proving out just a few of much better uptick. We're hesitant to become overly optimistic uptick.

We're hesitant to become overly optimistic because it's such early stages at this point.

I would say it clearly exceeds even our kind of worst-case scenario expectations, I would say even kind of our what I would call more moderate case scenario, it's performing better than that through scenario, it's performing better than that through May in terms of scheduling at this point, but it's so early, right? And as the country starts to reopen and as people start to get out more, and then how this, ultimately, gets reported around the potential spread if the pandemic does continue to spread, and how that, ultimately, influences then both patient behaviors as well as surgeon behaviors is such an unknown that it's really hard for us to articulate that we expect these trends to get back to normal by June.

It's just too early. But give us two more weeks, and we'll start give us three more weeks, and I think a lot of are more give us three more weeks, and I think a lot of are more confidence. But what again, what I would say is, every data point that we would want to see to give to see to give us optimism right now are happening.

And that includes both patients being open-minded and wanting to get procedures scheduled, physicians wanting to get back to work, new physicians wanting to have a place that's safe, that they can recommend place that's safe, that they can recommend to their patients and using our facilities.

The government being available and helping with all the PPE means now to the point that we are getting the PPE means now to the point that we are getting the access to ramp-up at a rate that we don't think will cause an access problem to PPE. And honestly, our And honestly, our employees are excited. They all want to get back to work.

And so I feel like we couldn't ask for right, ask for right, at this point in time, more tailwinds around optimism other than it's two weeks in, and we probably also just hold our breath a little bit longer and make sure we get through May 1.

But Eric, anything Eric, anything else you want to elaborate on?.

No. I mean, I think you covered it really well. I guess on the patient-specific question, it varies by market. We've had some markets where they've had virtually 100% success with rescheduling, and other markets where it's been a little more cautious. Obviously, that has a lot to do with the cautious.

Obviously, that has a lot to do with the local impact, and it has a lot to do with the local impact, and it has a lot to do with the local physician community. But I would agree with Wayne. I mean, I think, we are positioned really well. The really well. The early signs are good. It's a ramp faster than early signs are good.

It's a ramp faster than would have expected. And beyond that, I think we'd be foolish to probably try to predict too much in the future..

Yes. Okay. Fair enough. If I could sneak in just one more. Wayne, I may have misunderstood or misheard you, but I thought you mentioned alternative ways to get capital looking at into the organization to take advantage of growth. I was organization to take advantage of growth.

I was hoping you could flesh out those comments or if I misinterpreted? Anything any more details there would be helpful..

Yes. Thanks, Ralph. I would not read too much into the words I chose in that. What I would tell you is, we were feeling very good about our company.

And when we saw how strong our January and February was turning out, with not only the double-digit growth, but the fact that we were driving the vast majority of it through same store and the M&A pipeline was the M&A pipeline was Board for a while now about opportunities to get more capital into our company and to potentially go on the offensive.

But as with any discussion we have with our Board, that has to be weighed against trade-offs and what that looks like, and how is it though, that net value-creating for all of our shareholders? And we spent two years building this chassis. This chassis was exploding in January and February. We were prime to really take off from there.

We've got to manage this short-term window, but that's not going to stop our discussions with our Board around the fact that we want to get back on offense now, and we've got a plug-and-play model now that really works well that people want to be part of.

And so, at some point, if we really want to accelerate the M&A we really want to accelerate the M&A machine that we have here, it's going to require more capital than we have today. That being said, I just want to remind you, we've got over $400 million plus of consolidated cash, and we have and we have choices today.

And if may continues to ramp up and June continues to ramp up from there, we can either use that capital to delever, which will be a board decision. We can use it to deploy into M&A that's not under LOI at multiples below our current leverage ratio. And so we have a lot of optionality right now. But don't read more in the optionality right now.

But don't read more in the comment beyond the idea that we want to go on offense, though, once this passes..

Okay. And Ralph, one thing I might add there is I would remind you that double-digit growth that we talked about was without M&A, right? So our company organically is performing really well. organically is performing really well.

And that And that growth that we can drive between just operations, all the different initiatives we talked about over time, we feel good time, we feel good as a way to help us grow and, obviously, hopefully, help drive down the leverage over time as we grow that. But clearly, the M&A pipeline was as strong as it's ever been coming into this.

We feel like it's only going to get stronger. So we'll be continuing to talk about that. But the good news is, I want to go back to our double-digit growth model this year, did not assume M&A in it. assume M&A in it. that's going to change that. But going forward, that's still our outlook..

Our last question comes from Frank Morgan with RBC Capital Markets. Please go ahead..

Good afternoon. Quick question. I appreciate the color on your most important states and the timing of when those reopened.

But as you've looked at those individual states, are you seeing any variation in terms of the kind of business that's coming back in terms of surgical mix in those really important states, the Texas and the Florida, are you seeing one particular type of surgery, maybe it's a higher dollar procedure volume versus others? Just any color there.

And then just any general color on I think you mentioned certain geographies are back to full capacity.

Just any particular logic behind where you're seeing that capacity normalize the quickest? Anything you could attribute to?.

Frank, it's going you asked this question because Eric, Tom and I were literally having a discussion today looking at trends, trying to see if we could see trends that would point to one acuity over another acuity, etc. And so I'm going to let And so I'm going to let Eric comment on that since he's been the one diving in and really digging into this.

Relative to locations, again, it's been interesting. You look at some of the states that have opened, that have really not quite seem to have the same impact like you saw in New York, where we have no facilities today.

And you look at states like Texas, that has had really good optimistic rescheduling, Florida, and had really good optimistic rescheduling, Florida, and California. So when you start thinking about warmer states, we don't know whether that's coincidence or not, and so it's hard to tell.

But Eric, maybe you can comment a little bit around kind of the acuities can comment a little bit around kind of the acuities and then other trends because we have other markets, though, where we haven't seen much impact like Idaho Idaho and Montana.

And those are other examples where, over time, meaning there's been impact, but we feel like those are also up and those are, obviously, colder environments. So it's running. And so again, hard to really pinpoint if there's any unique nuance out there.

But Eric, anything you want to highlight?.

Yes. So Frank, I would start with I'm not going to read a lot into a trend a couple of weeks old, but certainly by market, we're seeing most of the states that are opening up showing positive trends and actually momentum that we think that we think starts to move us back toward a normal world.

From a specialty standpoint, look, I want to reiterate my point earlier, is around which PPE. With PPE pipeline getting rebuilt, and again, we're not out of the clear in the country, we feel good about where we sit today, there isn't a reason that our purpose-built focused our surgical hospitals or our ASCS. And so acuity. acuity.

Now I would say what we are, obviously, doing is we are prioritizing higher acuity procedures that are causing pain, discomfort for patients. We're prioritizing them on the schedule first. But even our single specialty centers that might just be GI or ophthalmology, we're not seeing that be an impact.

Really, the idea is, if you have a GI procedure or you need a cataract fix, trust me, if you're that person, it's something you want to get done, and we can do it safely as long as we have the PPE. So I don't think that's actually going to play out as part of this. I think we should be able to accommodate all of these needed procedures.

And early on, you might see a bit of an acuity jump just because of the importance for that patient being prioritized from a pain and urgency standpoint, but I don't think it's going to affect our mix..

This concludes our question and answer -- go ahead..

Some final comments. I guess, again, I just want to reiterate that there's reasons to be optimistic, but we would recommend caution at this point until we really see how things open and progress. It's still very early stages of reopening.

But we do appreciate, really, I want to say, on behalf of the Board of Directors of Surgery Partners Health, much we've been encouraged by the position this management team is taken, how aggressively they've moved on many things and how they've really positioned us to really be available to help the patients.

Eric, any final comments you would like to make?.

Yes, absolutely, Wayne. Before we conclude the call, first of all, I appreciate everyone's questions, and nice to be back with you today. I did want to take a moment just to join my colleagues and say, thank you, to our over 10,000 associates, our over 4,000 physicians for their contributions and their efforts throughout this crisis.

And more importantly, their commitment to really delivering on our mission statement, which is to enhance patient experience through partnership. We are humbled by the efforts of doctors, nurses and other first responders across the nation as they fight this pandemic and save lives. And I just want to thank you all for joining the call today.

We hope you all remain safe and healthy. And Wayne, if you don't have anything else, I think that concludes our call..

Nothing else for me. Thank you, Eric..

The conference is now concluded. Thank you for attending today’s presentation. You may now disconnect..