Michael J. Culotta - Wayne T. Smith - Chairman and Chief Executive Officer W. Larry Cash - Chief Financial Officer, President of Financial Services and Director.

Albert J. Rice - UBS Investment Bank, Research Division Frank G. Morgan - RBC Capital Markets, LLC, Research Division Gary Lieberman - Wells Fargo Securities, LLC, Research Division Whit Mayo - Robert W. Baird & Co. Incorporated, Research Division Brian Tanquilut - Jefferies LLC, Research Division Kevin M.

Fischbeck - BofA Merrill Lynch, Research Division Ralph Giacobbe - Crédit Suisse AG, Research Division.

Good morning. My name is Jeremy, and I will be your conference operator today. At this time, I would like to welcome everyone to the Community Health Systems First Quarter 2014 Conference Call. [Operator Instructions] I would now like to turn the call over to the Vice President of Investor Relations, Mr. Michael Culotta. Please go ahead, sir..

Thank you, Jeremy. Good morning, and welcome to Community Health Systems First Quarter Conference Call. Before we begin the call, I would like to read the following disclosure statement. 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 risk, which are described in headings such as Risk Factors in our annual report on Form 10-K and other reports filed with the Securities and Exchange Commission.

As a consequence, actual results may differ significantly from those expressed in any forward-looking statements in today's discussions. We do not intend to update any of those forward-looking statements. With that said, I would like to turn the call over to Mr. Wayne Smith, Chairman and Chief Executive Officer. Mr.

Smith?.

Thank you, Mike. Good morning, and welcome to our first quarter conference call. Larry Cash, our President of Financial Services and Chief Financial Officer is on the call today, as well as Lynn Simon, our President of Clinical Services and Chief Quality Officer.

After the market close yesterday, we issued an 8-K including a press release with our financial statements. For those of you listening today to the live webcast of this conference call, a supplemental slide presentation has been posted to our website.

This has been a very active quarter for us with the financing of the company in early January, the closing of Health Management Associates acquisition and implementation of the Affordable Care Act, and of course, the impact of the very severe weather we experienced. Let's start with the impact of the weather.

As Fred Smith, the FedEx Chairman, President and CEO, stated in his opening remarks of his earnings call, he said, and I quote, "In fact, it has been the toughest winter in which FedEx has operated." I'd like to state the same fact that this has been the most severe winter weather in which we have operated in our history.

In fact, this is worse than the winter weather I had seen in 1997 and -- 1977 and 1978. Saying that, I'd also like to put in perspective our geographic locations compared to our peers. We have more hospitals in areas significantly impacted by the severe winter weather than our public company peers combined.

There were 130 of our facilities that had some form of volume and financial impact on the operations, especially in the states of Pennsylvania, Indiana, Arkansas and Illinois. These 130 facilities represent 65% of our entire portfolio of hospitals.

So I think you can see how this has impacted us more than our peers and why we've been mentioning this throughout the quarter during our public presentations. But saying that, I'm extremely pleased with our financial and operational results that we've been able to achieve this quarter.

This is the first quarter that we reported our combined operations with HMA. Our first quarter results consolidate the results of Community Health Systems and the CHS '14 facilities from and after January 27, 2014. Prior year's first quarter historical financial information includes that of CHS only.

The same-store results reflect the HMA's performance from February 1 forward, both 2013 and 2014, as well as the CHS for all 3 months. Our net operating revenues increased 28% on historical comparison to $4.2 billion. Our adjusted EBITDA increased approximately 9.2% to $541 million.

The weather impact on adjusted EBITDA was approximately $25 million, which is not included as an add-back to the adjusted EBITDA of $541 million. Our adjusted earnings per share from continuing operations for the quarter was $0.27.

All calculations exclude the early extinguishment of debt relating to the financing that transpired, the costs associated with HMA acquisition and transition costs, amortization of abandoned software cost, the CVR legal expenses and the impairment of long-lived assets, but does not include the loss from weather impact of $0.14 per share.

Excluding the weather impact, our adjusted earnings per share would have been $0.41. Turning our attention to the HMA integration. David Miller has done a great job of focusing our resources on getting the acquisition fully integrated and working with Dr. Lynn Simon on all of our quality initiatives.

We hosted a meeting of the CHS '14 hospital CEOs, CFOs and CNOs in February as we rolled out our philosophies and expectations. We were very impressed with how everyone is embracing renewed support and additional attention. In addition, David and his team, as well as Dr.

Simon and her team, have been very proactive in meeting with the physicians throughout the organization, as we show our full attention to their needs. Let's remember, this is not about 1 quarter but long-term opportunities, especially with Affordable Care Act benefits this offers our company and our shareholders.

Of course, we have challenges along the way, but we expect this will bring rewards to our shareholders. As it relates to opportunities, we're very bullish on our ability to achieve synergy levels that we've discussed before. We still believe we will achieve $100 million in synergies in 2014, and $250 million in total over a 2-year period.

We have estimated that we will have already achieved $12 million in synergies just in 2 months. Let's now discuss our physician recruiting. As always, we are very focused on physician recruiting. We have over 22,000 physicians on our medical staff, of which 3,300 are employed.

We recruited 613 physicians this quarter compared to 418 on a combined company basis a year ago. We're extremely focused on further expanding our physician base. This will be extremely important as the Affordable Care Act gets further rolled out and effected. Dr.

Simon and her team are very focused on our quality measures and we continue to see vast improvements there. We are seeing approximately 15% reduction in our Serious Safety Events. In addition, our hospital-acquired conditions have been reduced approximately 23% since 2011.

Our readmissions for diagnoses included in the Medicare readmission reduction program have been reduced approximately 19% over the same timeframe. As you have seen in our announcement in early April, we completed 2 acquisitions this past month that will be included in our second quarter results.

Sharon Regional Health System, a 241 licensed bed facility located in Sharon, Pennsylvania, with 22 satellite centers in Munroe Regional Medical Center, a 421 licensed bed facility and located in Ocala, Florida, with an outpatient ambulatory center located approximately 10 miles west of Ocala.

These 2 acquisitions further our strategy of concentrating on our existing markets where we can further our network development. We're also excited to have Shands University of Florida as a minority equity partner in Ocala.

These regional partnerships with high-quality institutions such as Shands are part of our overall strategy to be the leader in health care in our communities. These 2 facilities have approximately $475 million in annualized revenue and they were included in our guidance that we gave in February.

I would like to give you a brief update on the pertinent legal matters. As it relates to the government investigations in the short state admissions and other investigations at Laredo, Texas facility, we continue to work toward final resolution and believe we could be close to the final outcome of this matter.

The reserve for this matter remains at $101.5 million, which we believe to be adequate to resolve the government's claims.

With regard to HMA's government investigation lawsuits, we have transitioned all these matters to our experienced in-house and outside counsel and are fully cooperating with the government on the investigation of these allegations.

As we stated previously, we were aware of the nature of investigations prior to closing and are working to resolve these matters, hopefully without having to fully litigate the many cases. However, we are in the very early stages and do not have a timeframe on when these matters will ultimately be resolved.

We are handling these matters with the belief that we will try to have as little disruption as possible and we'll keep our Board of Directors fully informed so they can perform their oversight responsibilities.

We've just updated -- we've just adjusted our updated -- our upper end of our guidance to the narrow -- the widening that narrowed the wider than usual range respect -- reflect the effects through the first quarter and reflect the movement of hospitals to and from discontinued operations.

The range of net operating revenues less provision for bad debts is now $19 billion to $19.8 billion. The range for adjusted EBITDA is $2.825 billion to $2.975 billion.

Larry will now discuss further our results, details of the extreme weather impact on our operations, the effect of the Affordable Care Act and provide you with other information on our 2014 guidance.

Larry?.

The share count in the second through fourth quarter will be larger due to the shares issued in late January that have outstanding for all 3 months of each of these quarters. We're not changing the guidance on our number but you will -- have around approximate average range of 115 million to 116 million shares in the last 3 quarters of 2014.

Remember, the HITECH reimbursement has been achieved mostly in the second half of the year. Our synergies of $100 million will grow throughout the year and are not evenly distributed. Second quarter synergies are estimated to be approximately $25 million, the other 65% will come in the second half of the year.

We still believe the Affordable Care Act rollout as the year progresses and will be much more of a second half improvement with probably approximately 75% being recognized in the second half the year. We filed an 8-K on April 8, 2014, which we included the reconciliation on the HMA adjusted EBITDA.

Based on our work, we estimate the impact on 2013 EBITDA run rate is about $35 million, for a run rate of $725 million. The California provider tax that we received about $17 million in the second quarter 2013 will not be there in the second quarter of 2014.

Although as we said on our last call, we'll receive about -- expect to receive $25 million for the California provider tax in the fourth quarter 2014. We've also included on Slide 18 a bridge for our adjusted EBITDA to our guidance. And Wayne will now provide a brief recap..

Thanks, Larry. We're very pleased with what we've accomplished this quarter in light of all the effects of the weather. Know that the recent acquisition with our other facilities will further our efforts to increase shareholder value and become a larger play in the new and improved health care environment.

We are very focused on our historical volume trends and are expanding our efforts in terms of being focused on the various avenues of consumer-driven health care. We continue to focus on enhancing our quality metrics, building stronger physician relationships, including increasing physician recruiting and doing what's right for our patients.

I'd like to thank all the physicians and nurses and support staff for all their tremendous support during this quarter as we move this company forward as one. With that, we'd like to open up the call for comments. If you have further follow-up questions, as always, we're here to take your calls. You can reach us at area code (615) 465-7000.

So I'll turn the call back to Jeremy to open it up..

[Operator Instructions] And your first question comes from the line of A.J. Rice from UBS..

Just a lot of numbers going around and there's obviously a lot of moving parts in the first quarter results.

If you sort of conceptually think about x-ing out weather, x-ing out HITECH, some of these numbers that are bouncing around, and you think about the legacy, community legacy HMA portfolio, first quarter to fourth quarter, are we seeing, from a volume perspective, from an EBITDA perspective, stability sequentially at this point? Are we seeing an uptick in improvement or how would you describe where you're at fourth quarter to first quarter?.

A.J., let me kind of start with this before Larry gets to the details of it. I think what we've been able to accomplish so far, we think are very positive results. Our integration is going extremely well. We have a very talented team.

We're ahead of where we were in the past in terms of how we did Triad, as far as identifying issues and problems and solving problems. Our synergies are coming along. We've done a good job in terms of working our way north from Naples to Nashville. So all that has come along and we've identified a lot of opportunities for us.

Having said that, while we're doing this, and we do have a very experienced operating team, our division presidents are very skilled, we've been focused on volumes and looking at volumes.

And as Larry said, I don't know if you quite got this or not, we normally don't talk about prospectively what the -- by month, but our margin, April volume trends were within our new guidance. So we think that is an indicator that things are at least moving the right direction.

We've made a number of adjustments in the way we think about our volumes and we're focusing on working through those. So I am pleased with the progress that we're making. Again, this is the first quarter in a long process for us to assimilate the 71 new hospitals. So I think we're making good progress.

And I'll turn it to Larry to talk about the numbers..

Yes, A.J., I think we had a slide out that said if you were $497 million, if you backed out the HITECH and adjust for divestitures that were in existence on HMA and also the 1 month we didn't have it, and then, if you put in the $40 million EBITDA, you get $537 million. I believe it was $39 million, although at the time, we'd estimated $30 million.

On top of that you've got considered the weather that happened from the fourth to the first. If you look at the volume for a second, the consolidated volume was down about 8% -- or same-store volume down about 8%, we're down 10.5% in the fourth quarter from CHS legacy. HMA had another similar type -- little bit less than that but still down.

I think adjusted admissions for us were down 6.7%, and they were down, combined, 5.3%, and HMA was probably a little under 6% or so at that point in time.

One of the challenges with the fourth quarter or any quarter for HMA was it had a roller coaster, okay first quarter, not a great second quarter, sort of really bad third quarter and a bounce back in the fourth quarter. Some of the accounting adjustments that took place that we talked about affected some of the activity there at the end of the year.

But I think we made good progress. I mean, we would have thought somewhere in the $500 million to $530 million range to $560 million range would have probably been what would be accepted. You've got to -- we did have a small benefit of the Health Care Reform of $10 million, you had the synergy activity.

But if you add the weather, we were estimated at $25 million, we actually did some calculations, it was higher than that and decided that, that would be the number we'd go forward with, it was difficult. The synergies are going to grow a lot, the Health Care Reform is going to grow a lot and we've got to do a better job in volume.

And it's wanting to sit at least the last -- most recent 2 months got to look much better..

Okay. And maybe one other sort of high-level thing. You said that one of the focus points was to meet with the physicians as much as possible. Any takeaways on what you're finding on the HMA side and the meetings with the physicians? And I guess, that segues into the -- your comments about recruiting and what you were doing there.

Is HMA -- does that recruiting effort have to just pretty much be rebuilt or was there much going on there?.

Yes, fortunately, from a recruiting standpoint, we said this all along that we have a very sound, very strong recruiting team, so we were able to just pick up the slack there. If you look at it historically, HMA's recruiting has dropped off quite a bit in the last number of quarters. So that's one of the issues that they've had.

In terms of medical staffs, we have been very well received. They're hungry for information, they're hungry for help. And as you know, Dr. Simon and her team have done such a great job in terms of quality. They're very receptive to all of our quality initiatives, including working with some Serious Safety Events.

So and that is creating opportunities for us in the markets -- in the marketplace. So all that's been very positive..

Your next question comes from the line of Frank Morgan from RBC Capital Markets..

A couple questions on Medicaid expansion.

I was curious if you could -- if you believe there will be a follow-up impact from the momentum on Medicaid expansion that you saw in the first quarter? And was the decline in the uninsured volumes and increases in Medicaid, was that directly proportional to your exposure to all those states? Were there any states that had auto-enrollment in Medicaid?.

Those states saw pretty good enrollment. We had a little bit more success in Washington and Arkansas, a little bit slower success maybe in Illinois and Arizona, but everybody saw a pretty good uptick from that perspective. There's a couple states -- 3 states of ours that are trying to expand Medicaid. Hopefully, they'll get that done.

I expect us to continue to see, as people either come to the hospital or we continue to some of our outreach efforts to find more people be enrolled in Medicaid going forward. And again, we'll continue to – if we find someone who's got a qualifying event we can enroll those people in exchanges. The exchange activity will get much better.

I mean, the enrollment activity grew throughout the quarter. Clearly, I would hope that we'd see some benefit in our markets and our efforts and be able to quantify it a little better. Unfortunately, a lot of the payers just don't identify the exchange patients as well as we've got the Medicaid patients identified..

Frank, I don't know if you saw the paper this morning here in Nashville, but Blue Cross, I think, is saying that they had 132,000 people enrolled in exchanges, which is a large number for the State of Tennessee..

And it was a big increase in December, off of what they had, so..

All of the companies that reported so far, they've talked about the increase in uninsured is greater than the increase in Medicaid volume, or do we presume that all those other people are going in, are these previously uninsured just going into exchanges or is there something we're missing there?.

Well, some are going in exchanges. But to some extent, the weather and the lack of flu will expect -- will affect some of the self-pay business, so it's not a one-for-one relationship. But there are -- some of the people went in exchanges. I know we can identify some member admissions off the states that we've got done.

And I think as we continue to have more quarters, more information, we'll talk more about the exchange business..

Okay. Just one more and I'll hop.

Any thoughts on best chances of incremental states going into expansion sometime later this year or next year?.

Yes, I think we got to get through this midterm elections, 2014 midterm election. Most Republicans, as my understanding, are concerned about the Tea Party knocking them off in these -- early, once you kind of get to that, we already know that there are certain states like Pennsylvania and Missouri, there's one other, Larry, I think....

Utah..

Utah are thinking about expanding now. And then I think as this continues to develop and people begin to get an understanding of what it's doing for the uninsured population, not only in terms of coverage but in terms of health, improving their health, you can't -- it's hard to improve your health if you don't have access to health care.

I think you'll see other states come around. And it'll be much more acceptable after you kind of get through this midterm election. So I think there's some hope there that we'll see, particularly -- I mean, Tennessee is a good state as well that will probably do something of some kind in the future..

And only other comment I'd say, a lot of people look at admissions, Frank, it's probably a better review on adjusted admissions since a high percentage of the activity for self-pay is outpatient, which is factored in the adjusted admissions. So that gives you a much more better correlation..

Your next question comes from the line of Gary Lieberman from Wells Fargo..

You mentioned presumptive eligibility and the use in some states.

Can you give us some more color in terms of which -- who you're using it for and how you're using it and how the payments have been?.

Yes, there's 3 states, I think we talked about there. And all states were supposed to adopt it. They've been a little slow, especially the, what would be called the red states. We're using it to try to determine based on information that we believe that someone is Medicaid-eligible who we'll classify them as Medicaid.

They're still go into Medicaid pending, but we're using that to try to make a positive if they are Medicaid, and once we get comfortable with that, then we'll classify that as a Medicaid patient. And it's much more sure that they'll be Medicaid.

To the extent that we use presumptive eligibility and we turn out, for some reason, not to be right, we'd still be paid as Medicaid, we just need to do proper work. That will help.

There's about 8 million to 10 million people, when this got started, that were eligible for Medicaid, not signed up for Medicaid throughout the country, so that'll help a great deal, will also help in the states to expand Medicaid, trying to get the people in the program a little easier, a little faster..

And then just in terms of reserving for the bad debts on the individuals as you booked them in Medicaid pending, are they -- are you -- I'm not sure if you said, but are you booking them as uninsured and then moving them in or are you taking some kind of mix of reserve policy?.

Based on history, we take 50% of the Medicaid pending and think they'll get certified as Medicaid and take a contractual on that. The rest of 50% goes in the self-pay and stays as a bad debt reserve..

Okay. And then, surgeries were down 5%.

Anything in particular about the markets that were weak?.

It was pretty much across the board. We still had just a little bit of growth in orthopedics, which we've had for a while. But most other lines were down. I think, I did say about 25% of that drop is probably related to the weather, as best we could tell..

Your next question comes from the line of Whit Mayo from Robert Baird..

Larry, can you go back to just the volumes in the quarter for the second -- just for a second. You said that March and April were better.

But I don't think HMA was in your numbers for January, did that have an impact? And maybe can you just walk us back through why you think the trend line should improve fairly meaningfully for rest of the year?.

Yes, if you look, January was a pretty bad -- it was the worst month of the quarter, and HMA was not in there. And then HMA went in on February 1. Both January and February were substantially down, more on an adjusted admission basis, than April and March.

As we said that were pretty close to the original guidance of minus 3%, but they're clearly within the range now of 0% to minus 4%, and we saw that -- and also surgeries were better in the 2 months than they were for the first 2 months also.

So from that perspective, we know also that about half the volume drop was weather and respiratory and flu, so about 49% of it. And that predominantly hit January and February, although there's some weather effect in March. Looking at both months, there's a little benefit of having, I guess, Easter in April versus March a year ago.

So looking at both months, we saw a much better improvement. We've got a lot of initiatives going on in volume.

Wayne, you want to talk about some of those initiatives on volume that we got going on?.

Well, Larry has turned into the Willard Scott of this now in terms of the weather [indiscernible] so much on weather. But what we've done over the last number of months is to go back, rethink a lot of the things that we're doing in the past.

We've worked on improving, enhancing our analytics to make sure that we understand the things that are going on in our market -- the markets, we've taken service lines.

All of this is in relationship to our strategy where we're building regional networks and service line improvements and we're beginning to work hard about access points and enhancing and improving our access points through multiple different kinds of vehicles, everything from mini clinics to urgent care.

We, again, worked on our emergency services in terms of throughput and you'll see us doing a lot more in terms of marketing our emergencies. Our network development strategy is coming along really well. We have 11 networks now that are with a number of hospitals and urgent care centers and outpatient surgery and all of the above in that.

So we've enhanced our work around our physician relationships, even though, as you know, if you look at our satisfaction rates, we have a 91% rating among our physicians that they would use our facility for them or their families.

So I think, we are focused and doing the right things and there's a long, long list of things that we're doing but some of this is by market but there a lot of overall ones we're doing company-wide..

Okay. And then maybe just on the abandonment of IT.

Just what drove that decision to change out that particular vendor and can you remind us just what group of hospitals that was?.

Yes, that was Community Health System hospitals. I think we put in a systems conversion about a year ago with Cerner. It's another system, it's a good system, we just decided to go a different direction. There was 2 different systems, one's been in the company since 2001. One we picked up with Triad conversions.

And in some hospitals, we're still using the one we picked up with Triad, and it's a good system to work with in those locations. Looking at the cost of all of the stage 2 activity and conversion costs and things of that nature, we thought we could save some dollars on spending on IT, and we've had to spend quite a few dollars on it, by doing that.

And so we left these 2 systems, decided to replace those for stage 2 purposes with Cerner, or in some cases, stage 1, and we're in the process of doing that this year. As a result, something -- some of it has been replaced and some will be done this year.

So some of it went off as an impairment, then the other would go off as -- we'll have another quarter of about $42 million additional amortization, and in the end we'll have about 100 -- a little over $100 million of a runoff from there.

And we'll save the $100 million of the spending for -- with Cerner for both conversions we got to get done and then also with the stage 2 efforts..

Okay. A lot of numbers there.

So you'll actually -- I think, I caught the $100 million, that's the actual cash savings versus what you would have spent on the other system?.

That's correct. And then, on the noncash, there's $24 million of impairment and $42 million of it this quarter, next quarter, that'll be accelerated software amortization..

Okay.

And this might be a silly question, but you don't have to re-attest stage 1 if you change your systems, do you?.

No..

Okay. And maybe just on HMA, just updated plans for IT there, just how long you can keep their whole system going and whether or not that can get you to stage 2 and 3..

We've -- the former CO got replaced with a person new to the company, we've put some staff down there, it was experience with us. We'll use them for stage 2.

A lot of the features in our system we've gotten certified, we also will use our features for our computerized physician order entry and also for patient portal and those elements and also med host, it's a system from an ER that will use -- they use that we also use here. We think we can get our stage 2 money based on, best we can tell now.

We're also working on getting some of the physician incentives that they have not gotten for physicians. So the plan is, and they're part of the $250 million high-end HITECH number that we'll get for 2014, and we also expect to get some pretty good sized HITECH for them in 2015..

Your next question comes from the line of Brian Tanquilut from Jefferies..

Larry, if you don't mind just highlighting for us.

Is there anything as we think about the ramp between Q1 and Q2 other than getting 1 month more of HMA and the synergy ramp, is there anything that we should think about, especially as we look at the consensus showing $150 million ramp sequentially?.

Well, we are going to have a little bit of a timing difference around the California provider tax, somebody else talked about it last year. We got about $17 million in the quarter, that won't be there this year. The HITECH will probably go up somewhere around $40 million and somewhere around $60 million.

The synergies will go up, but not substantially more than they were the preceding year. We would hope to have -- continue to make some progress on the Affordable Care Act.

But we do think if you take the second quarter and you look at it and continue to roll forward in the third quarter and the fourth quarter, we've done the bridge of where we think we're going to get to for that.

If you take the weather and add back the first quarter and you sort of annualize that, you've got to add -- we've got a couple acquisitions we closed that Wayne mentioned on Munroe and Sharon, and we also got -- just talked about the year, you've got the HITECH will be a bigger amount, a big contributors, more synergies will be greater than the first part of the year.

And of course, Health Care Reform will continue to grow. And then you've got didn't know January. So we worked -- looked at it both -- we've spent more time looking at the year than we have the quarter, but the quarter will have some growth but not near as much as you'll see the second half of the year..

Okay. Got it.

And then as we think about the discussions with health plans for 2015, anything that you can highlight to us in terms of what the discussions are like on the exchange plans and on the regular commercial plans?.

We're probably 50% to 60% done for 2015. Our range has been originally 4% to 6%. I think we're within that range, about 90% done for 2014. Our managed care people have done a good job there talking about it. I think the exchange contracting, we're starting to have conversations there. We expect to get some nominal increases.

We'll wait and sort of see how they decide to treat their premium rates for the exchanges, but we would expect that we'll continue to get our 4% to 6% increase for managed care in 2015 based on what we know today..

Larry, are there changes in the network buildouts that they're doing on the exchange plans?.

For the most part, the fortunist [ph] at the top of markets has got -- we're in almost -- I think we've got 99% of our hospitals are in pretty good presence. I don't expect us to see that. We've got some narrow networks ran probably 40% of our contracts will be that.

I'd expect us to stay in it and I expect us to be in a position of strength when it deals with managed care, especially look to growth in the stage and one of the advantages of the HMA transaction, similar states with us, especially it helped us in Tennessee, it helped us in Pennsylvania, helped us Oklahoma, Mississippi, and of course, together, we're pretty strong in Florida..

I think McKenzie has got a study out that says about 70% of the networks are narrow networks now. So we're fortunate that we're in -- clearly, in the vast majority in our states without a problem..

Your next question comes from the line of Kevin Fischbeck from Bank of America..

I just want to go back to that kind of ramp up question just because, I think that is probably the biggest question in people's minds in that they see the 5 40 as a starting point.

And then, your guidance at the midpoint kind of assumes about a run rate of 7 86 per quarter each quarter in Q2 through 4, and it sounds like the number in Q2 is going to be a lot lower than that, which implies the number in second half of the year is going to be more like in the 8 50 call it type range.

I just wanted to see if we could put a little bit of number. You mentioned a number of the things in response to that last question.

But if we kind of think about HMA being in for the full quarter, maybe that's $65 million, HITECH just kind of thinking bridging Q1 to Q4, HITECH's going to be a lot higher, maybe $100 million, the California provider tax you mentioned $25 million, the deals you mentioned this year, I don't know if that's $10 million.

And then the synergies ramping up, you said you think you'll see $12 million in the first quarters. So maybe I should be thinking about $30 million -- or $20 million into Q4. And then, reform ramping up, could be, I guess, $35 million, $40 million.

I mean, is there anything else in there, because that kind of gets like an 8 20 number for Q4?.

I think the growth [indiscernible] we spent a lot of activity here, you had negative volume of over 5% here and we started -- basically, said we're running somewhere in the 3% to 4% right now. And as we continue to make some progress there, that we should also anniversary the 2-midnight rule in the fourth quarter which would be beneficial.

The sequester, which has been a hit is over with now and it's down in the run rate or the numbers.

So looking year-over-year, I think we've got a lot of the synergies activity that will be in the fourth quarter continuing to ramp up again, we're going to go from $100 million in 1 year to $150 million the second year, so you've got to have a pretty good run rate from that perspective.

The HITECH is usually always the highest number there, usually about 40% of the number in the quarter. That activity will be beneficial from there. The Health Care Reform, I think with the positioning we'll be in going into the year, I think we'll continue to have good open enrollment activity, and of course, people can join.

The Medicaid will continue to do better. We're very hopeful that Pennsylvania could come sometime before the next -- for the fourth quarter. That would be very helpful for us with the number of hospitals we got there.

And then we also got the Medicare roll forward [ph], which we expect to get sometime between now and end of the year, which could be the third or fourth quarter, $36 million. Everybody else has got that done. HMA have not got that done, and we're working to get that done, that's a good sized pickup.

The acquisitions, we'll continue to build, there's supposed to be a fourth acquisition come onboard sometime in the fourth quarter. That's a good sized facility, good margin plus we're doing some other smaller acquisitions of practices and surgery centers..

Okay. That's helpful. And if maybe you think about then a Q4 number that is 8 50 to plus range and annualize that and even if we adjust the timing of the HITECH, it sounds like the HITECH number for next year isn't going to be that much different than this year.

The starting point for next year is going to be just Q4 annualized 3.2 or more before you think about the synergies ramping up and reform ramping up and any kind of growth in the core business.

I mean, is that the right way to think about it or is there any other adjustments [indiscernible] HITECH [indiscernible]?.

I don't -- we don't have -- Kevin, we don't have back quarter estimates, but clearly, where we are today, the guidance we laid out, getting to around 2.9 is what that bridge does. That would require a pretty good ramp up and we've concentrate more in the second half of the year talking about the discussions.

And clearly, just by the seasonality, the third quarter would push forward those results into fourth quarter. So your answer is right. You've got to be careful about how seasonality falls out.

But clearly, the fourth quarter should be the best quarter we have and we should have the biggest benefit with synergies, Health Care Reform, HITECH, the growth efforts we've got going on, the expense savings we've got, and then -- so that definitely should be our best quarter. And that's up well.

I think as Wayne said earlier, it's not the first quarter that matters, it's the results we make over the next couple of years and we do expect to continue to grow throughout the year..

And we will take one final question and this from Ralph Giacobbe from Crédit Suisse..

I just wanted to go back to what you just said in terms of the roll forward. And certainly understand all the moving pieces but I want to go to the organic growth. I guess, it seems implied, I guess, about a 2.5% growth rate.

I guess, is there any comparable number to what the 1Q sort of growth was relative to that 2.5% so we could help understand sort of what the ramp would imply for even just the organic growth rate of the business? Obviously, last year, the business was under some pressure and the same-store results were down year-over-year and HMA has had those pressures as well.

So I think what would help would be just to understand sort of the comfort level around being able to grow the underlying base sort of exclusive of all the kind of onetime pluses and minuses that you talked about..

Well, the growth -- with the 5% growth of adjusted admissions, we had a greater than -- EBITDA decline in the 5%.

So but we -- if you sort of break out by quarters, the March and April have been substantially better results than the first 2 months, and that helps it immensely, there's a lot of moving parts there, so we're probably above 5% decline in the first quarter..

Okay. All right. That's helpful.

And then just wanted to clarify the -- in your prepared remarks, did you say -- was it $70 million in revenue that moved from discontinued ops into continuing ops?.

No. From continuing ops to discontinuing ops in revenue..

Got it. Okay.

And what was the -- would you give us what's the EBITDA?.

I don't think we disclosed it, it's a small margin….

Positive..

There was the HMA, so we were a little bit larger and the [indiscernible] was a small margin..

Okay. And then just my last one.

On a sort of combined pro forma basis, do you know what percentage of Medicare admissions now or 1-day stay?.

Of Medicare admissions, I think it's 5% of total admissions. Medicare is 5% of total admissions..

No. I'm sorry. What percentage of the Medicare is 1-day stay at this point? There's been a lot of pressure on that business..

It's 12% to 14%, in that range..

12% to 14%.

That's pro forma for both combined community and HMA?.

Yes..

And this concludes our Q&A session for today. I would now like to turn the call back over to Mr. Smith for closing remarks..

Thank you again for spending time with us this morning as we embark on another exciting chapter in CHS' history. Our standardized and centralized operating platform will help in moving the company moving forward as one and achieving our goals.

We want to specifically thank our management team, our staff, hospital executives officers, hospital chief financial officers and chief nursing officers and division operators for their focus on operating performance for this challenging quarter. Once again, if you have questions, you can reach us at area code (615) 465-7000. Thank you..

And this concludes today's conference call. You may now disconnect..