Victor L. Campbell - Senior Vice President R. Milton Johnson - Chairman & Chief Executive Officer William B. Rutherford - Chief Financial Officer & Executive Vice President Samuel N. Hazen - Chief Operating Officer.

A.J. Rice - UBS Securities LLC Andrew Schenker - Morgan Stanley & Co. LLC Sheryl R. Skolnick - Mizuho Securities USA, Inc. Kevin Mark Fischbeck - Bank of America Merrill Lynch Jason Plagman - Jefferies LLC Scott Fidel - Credit Suisse Securities (USA) LLC (Broker) Whit Mayo - Robert W. Baird & Co., Inc. (Broker) Sarah James - Wedbush Securities, Inc.

Ralph Giacobbe - Citigroup Global Markets, Inc. (Broker) Gary Lieberman - Wells Fargo Securities LLC Chris Rigg - Susquehanna Financial Group LLLP John W. Ransom - Raymond James & Associates, Inc. Matthew Richard Borsch - Goldman Sachs & Co. Ana A. Gupte - Leerink Partners LLC Joshua R. Raskin - Barclays Capital, Inc. Gary P.

Taylor - JPMorgan Securities LLC Paula Torch - Avondale Partners LLC.

Good day and welcome to the HCA Fourth Quarter 2015 Earnings Conference Call. Today's conference is being recorded. At this time, for opening remarks and introduction, I would like to turn the conference over to the Senior Vice President, Mr. Vic Campbell. Please go ahead, sir..

Chairman and CEO, Milton Johnson; Sam Hazen, Chief Operating Officer; and Bill Rutherford, Chief Financial Officer. Before I turn the call over to Milton, let me remind everyone that should today's call contain any forward-looking statements, they're based on management's current expectation.

Numerous risks, uncertainties and other factors may cause actual results to differ materially from those that might be expressed today. Many of these factors are listed in today's press release and are included in our various SEC filings.

Several of the factors that will determine the company's future results are beyond the ability of the company to control or predict. In light of the significant uncertainties inherent in any forward-looking statements, you should not place undue reliance on these statements.

The company undertakes no obligation to revise or update any forward-looking statement whether as a result of new information or future events.

On this morning's call, we may reference measures such as adjusted EBITDA and net income attributable to HCA Holdings, Inc., excluding losses, gains on sales of facilities, losses on retirement of debt and legal claim costs which are non-GAAP financial measures.

A table providing supplemental information on adjusted EBITDA and reconciling to net income attributable to HCA Holdings, Inc. to adjusted EBITDA is included in the company's fourth quarter earnings release. This morning's call is being recorded. A replay will be available later today. With that, let me turn the call over to Milton..

All right. Thank you, Vic, and good morning to everyone joining us on the call or webcast. This morning, we issued our full quarterly earnings release for the fourth quarter of 2015. The release is consistent with the preview of the fourth quarter we issued earlier this month.

And I'll make a few comments on the quarter and our strategy, and then I'll turn the call over to Bill and Sam to provide more detail on the quarter, health reform and 2016 expectations. We were extremely pleased with the results of the fourth quarter. Adjusted EBITDA for the fourth quarter totaled $2.131 billion and, for the year, $7.915 billion.

It was a record earnings quarter for HCA and also a record earnings year. The fourth quarter performance was a result of solid volume growth, improved payer mix and service mix and effective cost management. We believe the company is well positioned for continued success.

There are many aspects of the company that contribute to our consistency of growth and financial performance. Our growth strategy built upon our investments in developing health systems in large, fast-growing urban markets has been delivering strong top line growth.

To illustrate the consistency and effectiveness of our growth strategy, we have reported same facility admissions and adjusted admissions growth for eight consecutive years, ER visit growth for nine consecutive years and surgical growth for seven consecutive quarters.

We believe our strategies are well resourced and we expect to see another year of volume growth in 2016. The consistent execution of our growth strategy and consistent growth in adjusted EBITDA, which has grown from $5.9 billion in 2010 to $7.9 billion in 2015, has resulted in strong cash flows.

Since our IPO in early 2011, we have maintained a well-balanced shareholder-friendly approach to capital allocation. For example, since the IPO in 2011 through the fourth quarter of 2015, we have generated $20.1 billion of cash flows from operating activities.

Over the same period, we invested $9.7 billion in our markets through capital expenditures or about 48% of cash generated and returned cash to shareholders either in special dividends or by share repurchase in the amount of $9.3 billion or about 46% of cash generated.

The company had approximately $2.6 billion remaining under its $3 billion share repurchase authorization at year-end. We generated $4.73 billion of cash flows from operating activities in 2015, up 6.4% over 2014.

We continue to have a balanced approach to capital allocation in 2015, deploying approximately $2.4 billion in capital spending and approximately $2.4 billion in share repurchases. In 2015, we've repurchased approximately 32 million shares of our stock.

In addition to our financial performance, I was pleased with our progress with respect to our clinical agenda. In 2015, 106 or 78% of our eligible hospitals were recognized as Top Performers by the Joint Commission compared to approximately 31% of hospitals nationwide.

The Joint Commission's Top Performer status is the highest recognition for achieving excellence in evidence-based care processes for certain medical conditions.

In 2016, we will continue to leverage clinical technology, especially in concepts of big data, data analytics, and clinical informatics to deliver safe, high quality, and compassionate care for our patients. We will also continue our focus on programmatic development of service lines directed at expanding our clinical depth and capabilities.

We will remain committed to continuous improvement in the quality of care and service as we strategically position the company to deliver value for all of our stakeholders. I'll close my comments with my thoughts on our 2016 guidance that is included in our release this morning.

With respect to adjusted EBITDA growth, our guidance yields a 3% growth rate at the low point of the range and just under 7% at the high end. Our guidance reflects continued solid volume growth, reasonable pricing, and well managed expense growth, with little less contribution from Reform than the past two years.

We transition into 2016 with momentum and we believe the company is well positioned to achieve its goals for 2016. Now, let me turn the call over to Bill to provide additional detail on the quarter, health reform, and 2016 guidance.

Great. Thank you, Milton, and good morning, everyone. I will cover some additional information relating to the fourth quarter results and review our 2016 guidance. Then, I'll turn the call over to Sam for an update on operations.

As Milton commented, we were extremely pleased with the quarter's results and the quarter finished a very strong 2015 for the company. Fourth quarter was coupled with a good payer mix and service mix and solid expense management, which combined to drive the quarter and the year's strong performance.

For the quarter, adjusted EBITDA increased 8.9% to $2.131 billion from $1.956 billion last year. We reported an improvement of 50 basis points in adjusted EBITDA margin in the quarter to 20.8%.

As a reminder, in last year's fourth quarter, we recorded a $68 million increase to Medicaid revenues related to the Texas Medicaid Waiver Program, reversing the reduction we had made in the third quarter of last year.

Adjusting for the impact of this item as well as a decline of $27 million in EHR income and an increase of $24 million in share-based compensation, adjusted EBITDA grew 15.4% over the fourth quarter of last year. Now, let me speak to volumes.

In the fourth quarter, our same facility admissions increased 1.6% over the prior year and equivalent admissions increased 2.9%. Sam will provide more commentary on our volume trends in a moment. During the fourth quarter, same facility Medicare admissions and equivalent admissions increased 0.6% and 1.8% respectively.

This included both traditional and managed Medicare. Managed Medicare admissions increased 6.3% on a same facility basis and represent 32.8% of our total Medicare admissions. Same facility Medicaid admissions and equivalent admissions increased 3% and 4.8% respectively in the quarter, consistent with trends we experienced in the third quarter.

Same facility self-pay and charity admission increased 8.6% in the quarter, representing 7.7% of our total admissions compared to 7.2% last year. Managed care and other, which includes exchange admissions, increased 0.6% and equivalent admissions increased 1.9% on a same facility basis in the fourth quarter compared to the prior year.

Same facility emergency room visits increased 3.6% in the fourth quarter compared to the prior year. And same facility self-pay and charity ER visits represented 19.6% of our total ER visits in the quarter, which is consistent with last year.

Intensity of service or acuity continued to increase in the quarter, with our same facility case mix increasing 2.1% compared to the prior year period. Same facility surgical volumes increased 1.9% in the quarter, with same facility inpatient surgeries increasing 1.5% and outpatient surgeries increasing 2.2% from the prior year.

Same facility revenue per equivalent admission increased 2.6% in the quarter. Same facility managed care and other, including exchange revenue per equivalent admission, increased 5.6% in the quarter, generally consistent with our third quarter results.

Same facility managed care and other, including exchange case mix, increased 2.4% compared to the prior year. Same facility charity care and uninsured discounts increased $494 million in the quarter compared to the prior year.

Same facility charity care discounts totaled $958 million in the quarter or an increase of $46 million from the prior year period, while same facility uninsured discounts totaled $2.873 billion, an increase of $448 million over the prior year period.

Now, turning to expenses, expense management in the quarter was good as we were able to leverage strong volumes and a higher intensity of service. We also saw improvement from our Q3 expense levels as a result of various management actions we began last quarter.

Same facility operating expense per equivalent admission increased 1.2% compared to the last year's fourth quarter, and sequentially, operating expense per equivalent admissions declined 0.3% from the third quarter of 2015.

Salaries and benefits, as a percentage of revenue, increased 50 basis points to 44.9% compared to 44.4% in last year's fourth quarter. Sequentially, salaries and benefits as a percentage of revenue improved 200 basis points from the 46.9% we reported in Q3 of 2015.

Same facility supply expense per equivalent admission declined 2.1% for the fourth quarter, compared to the prior-year period, and improved 80 basis points, as a percentage of revenue, from last year's fourth quarter, reflecting continued success on several supply chain initiatives. Our pharmacy cost trends moderated slightly in the quarter.

Our total pharmacy cost was up approximately 9% in Q4 compared to the 13% increase we reported in Q3 of 2015. Other operating expenses improved 50 basis points from last year's fourth quarter to 18.0% of revenues.

We recognized $1 million in electronic health record income in the quarter, compared to $28 million last year, and this was consistent with our expectations. As previously mentioned, our adjusted EBITDA margins for the quarter increased 50 basis points over the prior-year period.

But adjusting for the $68 million Texas waiver item in 2014 and the changes in EHR income and share-based compensation, adjusted EBITDA margin increased 150 basis points for the quarter over the prior-year period. Let me briefly touch on health reform activity in the quarter.

In the fourth quarter of 2015, we saw 11,238 same facility exchange admissions, as compared to the 7,700 we saw in the fourth quarter of last year, and comparable to the 11,445 exchange admissions we reported in the third quarter of 2015.

We saw just under 38,000 same facility exchange ER visits in the fourth quarter, compared to 25,600 in the fourth quarter of 2014 and the 40,200 we reported in the third quarter of 2015.

When we roll all the components of health reform that we can track, we currently estimate health reform contributed just under 6% of adjusted EBITDA for the full-year of 2015, and that was in line with our expectations. So all in all, a strong quarter that finished a very strong year for the company. Let me touch briefly on cash flow.

Our cash flow remains very strong. In the fourth quarter, cash flow from operations was $1.558 billion compared to the $1.627 billion last year, which is primarily a result of changes in working capital offsetting the increase in net income.

For the full-year of 2015, cash flow from operations was $4.734 billion, up from $4.448 billion last year, and free cash flow for 2015 was just over $1.864 billion. At the end of the quarter, we had approximately $2.179 billion available under our revolving credit facilities. So now let me move into a discussion about our 2016 guidance.

Highlighted in our earnings release this morning, we estimate our 2016 consolidated revenues should range from $41.5 billion to $42.5 billion. We expect adjusted EBITDA to be between $8.15 billion and $8.45 billion.

Within our revenue estimates, we estimate equivalent admission growth to range between 2.5% and 4% for the year, and revenue per equivalent admission growth to range between 2% to 3% for 2016.

We anticipate our Medicare revenues per equivalent admission to reflect a composite growth rate of approximately 1% to 2%, factoring in market basket changes and ACA reductions as well as some anticipated intensity increases.

Medicaid revenues per equivalent admission are estimated to be mostly flat year-over-year, excluding any changes in the Texas waiver revenues. And managed and commercial revenues per equivalent admission are estimated to grow between 4% and 5%. We expect a continued step-down of our EHR incentive income of about $40 million.

EHR-related costs are no longer being considered incremental expenses, but do remain in the system to support EHR and other ongoing automation efforts. We also anticipated growth in share-based compensation of approximately $40 million. So we anticipate operating expense per adjusted admission growth of approximately 2.5%.

Our guidance includes the estimated net impact of health reform. While we expect exchange volumes to continue to grow in the third year of health reform, isolating the net EBITDA impact of health reform from core operations is becoming more suggestive and increasingly difficult.

We will continue to report on exchange volumes, which we can identify, the converting these variables to an EBITDA impact has increasing imprecision. We believe Reform will continue to contribute to the growth of the company and a reasonable estimate today is Reform will contribute approximately 1% of growth for the company in 2016.

Relative to other aspects of our guidance, we anticipate capital spending to increase to $2.7 billion in 2016, which is in line with our three-year capital plan that we announced early in 2015. We estimate depreciation and amortization to be approximately $1.9 billion and interest expense to be approximately $1.75 billion.

Our effective tax rate is expected to be approximately 38%. And lastly, our average diluted shares are projected to be approximately 404 million shares for the year and earnings per diluted share guidance for 2016 is between $6 and $6.45. So that concludes my remarks, and I'll turn the call over to Sam for some additional comments..

Good morning. As mentioned earlier, the fourth quarter was another solid quarter for volume growth across the company and capped off a very strong year of growth for HCA. Again, this quarter we had broad-based growth across our divisions, and we had broad-based growth across the various service lines that make up our business.

To put a finer point on the consistency Milton highlighted, HCA has now grown its admissions and emergency room visits on a same facility basis in 18 out of the last 20 quarters. This consistency is not only seen in these growth metrics, but also, in any other areas of our business.

For the fourth quarter, the company had very low flu volumes, which reduced our growth in admissions by approximately 0.7% and also reduced our growth in emergency room visits by almost 2%. 10 of 14 divisions had growth in admissions and emergency room visits in the quarter. For the year, all divisions had growth in both of these categories.

13 of 14 divisions had growth in adjusted admissions for the quarter. For the year, all divisions had growth in adjusted admissions. And within the division, 86% of all HCA domestic hospitals had growth in adjusted admissions.

This broad-based performance reflects HCA's strong and diversified portfolio of networks and 42 domestic markets, most of which, we believe, still have good growth prospects. In addition to the strong portfolio performance, the company's growth across its diversified facilities and service lines was equally strong.

On a same-facility basis, in-patient surgeries grew by 1.5% in the quarter and 2.1% for the year. Surgical admits grew by 80 basis points to 28.4% of total admits in the quarter, and for the year, surgical admits were slightly up over the prior year at 27.5%. Outpatient surgeries grew by 2.2% in the quarter and 1.6% for the year.

Both components of this service line, hospital based and our freestanding ambulatory surgery center division showed solid growth. Behavioral health admissions grew by 7.9% in the quarter and 8.4% for the year. Rehab admissions grew by 6.4% in the quarter and 8.5% for the year. Deliveries were the only volumetric down for the quarter, it was down 1.8%.

However, managed care deliveries were actually up. For the year, deliveries were up 0.8%. Average length of stay increased 1.1% in the quarter and 1.3% for the year. These increases are mostly a result of the company's growth agenda, which includes developing a more comprehensive and complex level of services across our provider networks.

For example, trauma volumes across our growing network of trauma centers were up 27% for the year and cardiovascular surgery volumes were up over 6% for the year, which is a result of adding deeper, more complex capabilities to our existing programs. And finally, the company has been investing aggressively to expand its urgent care centers.

These centers improve convenience for our patients and increase access to our networks. This past year, we had over 1 million urgent care visits, a 500% increase.

Our urgent care centers coupled with 3.3% growth in the number of physicians, who have joined our medical staff, are making it easier for our patients to use an HCA network and improving our overall outreach efforts. As we move into 2016, we think HCA is well-positioned to succeed.

We believe macros for our markets are still positive and we believe the company is heading into the year with momentum. Demand growth in our markets is strong. We estimated that approximately 2% per year driven primarily by population growth and positive economic trends. The pricing environment is stable, and we have good visibility into our contracts.

The company is contracted for 85% of its commercial revenues in 2016, over 50% for 2017 and around 20% for 2018 at pricing terms that are consistent with the past few years. Market share is at an all-time high and opportunities still exist to increase it as we execute our growth agenda and increase our capital spending.

Over the next two years, we will add close to 1,000 in-patient beds and 400 ER beds to address capacity constraints and growth opportunities. The competitive landscape in HCA's markets is mostly unchanged. Complementary end-market acquisitions are available, especially, in the outpatient areas.

We have next-generation growth opportunities for many facilities within our portfolio. This past year, 80% of our hospitals had earnings growth. And lastly, we have a solid handle on cost trends, which we believe should be manageable in 2016.

In summary, we believe the company has the right strategy and a right approach to the market for sustaining growth. We believe the company is resourcing its growth agenda appropriately, and we are improving our ability to execute even better by investing in systems and specialization across the company. With that, let me turn the call back to Vic..

All right. Thank you, guys. And, Audrey, if you come back on and pole for questions. And we would like to keep questions to one at a time, so everyone gets a chance..

Thank you. And we will go first to A.J. Rice with UBS..

Thanks. Hi, everybody. So I'm just thinking about the EBITDA growth target for 2016. You've got a 3% to 7% at the high- and low-end of the range or low- and high-end of the range. And I think Bill made the comment that 1% of that is probably attributable to incremental Reform benefit. And you also mentioned high-tech and stock-based comp.

I guess, they're about a $40 million each headwind. So they're about 1%. They sort of eat up that Reform benefit.

So the 3% to 7%, is it right to think about that going forward as sort of the parameters around your organic growth? Can you give us some flavor for how you think about that?.

A.J., thank you very much.

Milt, do you want to take that?.

Absolutely. So, A.J., as you know, back in 2011 shortly after the IPO, we started giving long-term growth expectations for HCA again based on the conditions of the market, economic conditions, and the like. And we pegged that at about 3% to 5%.

And so as we look now at the markets, the improvement in economic conditions and the like, we feel a little bit better about our growth prospects. Obviously, we've had a good run here, especially, over the past two years really over the last five years, but especially, over the past two years.

And I feel like now we're more maybe in the 4% to 6% outlook. But, again, I caution to give long-term outlook and our industry right now with, again, some of the changes in developments, but we see it a little bit more favorably than we did, say, four years ago. And so, obviously, this year we feel good about our guidance in that 3% to 7% range.

But on a long-term basis, I'd probably peg it now at 4% to 6%..

Thanks, A.J..

Thanks..

We'll move next to Andrew Schenker at Morgan Stanley..

Hi. Good morning. I just wanted to discuss a little bit more about the utilization trends.

I mean, you obviously gave quite a bit of color about the economy, et cetera, but, I mean, even as 2015 progressed on kind of a two-year stack, you continue to see acceleration throughout the year, and your guidance remains quite strong for next year, especially, given the continued tough flu comp in 1Q.

Maybe just really, talk about what you are doing to drive this increased and strong volume trends and really how we should think about the long-term sustainability of these positive volumes..

All right. Andy, thank you. Sam's going to address that..

I think when you think about HCA's growth strategy, and we've spoken to this numerous times, we think, first and foremost, we have incredible markets where we do business.

And those markets are yielding, on a composite basis, across the company approximately 2% increase in demand growth just coming from population growth, as well as aging baby boomers, increasing employment and so forth.

On top of that, the company has achieved anywhere between 25 basis points to 40 basis points of market share gains over the past few years. And as we look forward, we see those basic components being similar to what I just laid out.

And so next year's guidance includes about 2% to 2.5% demand growth at this particular point with our estimate, and then roughly 25 basis points to 30 basis points of market share gains. Our approach to gaining market share is clearly built around being the provider system of choice for our patients and for our physicians.

And that involves four, five major dimensions that we invest in very, very aggressively. We monitor very, very closely.

And those are centered around, do we have the right network of outpatient facilities and ease of access, if you will, in the HCA's facilities, building out comprehensive service lines, I mentioned that in my comments, and then, working with our physicians very, very effectively to enable them to do what they need to do for our patients.

And we do that with one other dimension that we're investing in even more, and that's coordinating care across the HCA continuum and the HCA network. And that's yielding gains for us. Obviously, our capital spending is enhancing our growth, we believe, and putting us in a very strong competitive position within the markets.

And then, finally, I think the competitive advantage that HCA has globally across these markets is that we have an incredible amount of best practice and solutions that we can export from one market to another and put that to use in a very timely go-to-market-quickly kind of way.

And that gives us advantage, we believe, on all these dimensions, and globally, allows us to grow our business..

Sam, thank you. Thank you, Andy..

We'll take our next question from Sheryl Skolnick at Mizuho Securities USA..

Good morning, and thank you. Listen, this is a very different tone, and congratulations on achieving a record year, or record quarter. Hard work, well-rewarded. I'm going to go back, though, and ask about the cost trends here, because this is such a substantial change from our last call.

Can you talk about some of the things, I guess, that would be most probably a question for Sam that you've done to address the labor issues? Obviously, you're constantly monitoring them, but what's changed? What's improved? And should we now no longer be worried about nurse wage inflation and your ability to manage that cost going forward? Thank you..

All right. Sheryl, thanks. And, Sam, gets that one again..

Okay. If you look at the fourth quarter and you make one adjustment that Bill mentioned in his comments about the $68 million of waiver revenue that was sort of misplaced from the third quarter to fourth quarter – that's probably not the right term, forgive me, Bill – but that reduced our SWB to basically flat with the fourth quarter of last year.

So I was very pleased with that. What we saw year-over-year, and I'll speak to sequential in a moment, because I think the sequential performance is most important here, but year-over-year, we had about 1% improvement in productivity. We had a slowdown in the rate of growth in contract labor.

It did grow, but it's slower than what it had grown in the previous nine months of the year. And so those are some year-over-year kind of metrics.

But what was really impressive and what I was really pleased with our teams, and as I mentioned in the third quarter, we started to see this in September, but sequentially, we improved our productivity from third quarter to fourth quarter by 1.7%.

Now in the previous two years, we had improved our productivity from the third quarter to the fourth quarter in low tenths, like 0.1% in one year, 0.3% in the other. So very significant movement by our teams to make some adjustments in our productivity.

Contract labor did slow down, actually reduced by (32:28) 1% from the third quarter to the fourth quarter. So that was encouraging. And as we mentioned in the third quarter call, we did see some stabilization, but we actually saw a bit of improvement sequentially in the fourth quarter as compared to the third quarter.

I mean, contract labor still remains an opportunity for the company. Nursing contract labor is somewhere between 8.5% and 9%. That's stabilized a little bit, but, nonetheless, an opportunity.

As we look at what the company has been able to accomplish, I went back and studied, 80% of the last 20 weeks we've actually had a net gain in full-time RN positions across the company. And we've also dropped about 900 FTEs from orientation into supporting our patients. So I'm very pleased with the progress we're making in our hiring efforts.

Our One HR (33:22) program is starting to get its sea legs, if you will, and really yield some benefit for the company. And as we finish our rollout in 2016, I'm eagerly awaiting improvements there.

So as we think about wage rates for 2016, we are anticipating a little bit of acceleration, but something that's very, very manageable, we believe, within our overall budget. And so that's sort of the story on our labor for the fourth quarter..

Great..

All right, Bill....

Quick follow-on. I mean, in last quarter and the third quarter, we called out nursing turnover rates, again, the cause and effect of the contract labor increases. And we haven't solved the turnover issue in a quarter. We said that last quarter. And I really see that as an opportunity for the company in 2016 to improve that.

And we have several initiatives that we will kick off to try to improve turnover in nursing, and in response, we should see a corresponding improvement in contract labor costs going forward as well. So, again, just to make it clear, we haven't solved the turnover issue. We're working on it.

I expect to see improvement throughout 2016, and again, view it as an opportunity for the company..

All right, thank you. Thank you, Sheryl..

Great. Thanks..

We'll move next to Kevin Fischbeck of Bank of America..

Great. Thanks. I guess, last quarter you mentioned, I guess – a little bit about payer mix and what you saw in Q4 versus what you saw in Q3. I guess, last quarter specifically you mentioned Medicaid authorization slowing down in Texas and Kansas.

Did that come through and help the quarter, or is that still a drag? And what's your assumption about payer mix going into 2016?.

Yes. All right, Kevin. Thank you. Bill's going to take that..

Hey, Kevin. This is Bill. I'll start and give you some color on our uninsured, and maybe Sam wants to add into this. So you're right. Our uninsured admissions we called out in the third quarter. If you recall, we saw over a 13% growth in uninsured admissions in the third quarter.

That dropped in the fourth quarter to just under 9%, 8.9% in the fourth quarter. As we mentioned in our calls in the past, there have been some noise when we do year-over-year comparisons, mainly because of the first year of health reform and Medicaid conversions.

We did, as you mentioned, identify some processing issues in the third quarter of Medicaid applications in Texas and Kansas. We did see some improvements there, didn't necessarily have a material effect on us in the quarter. Just as a reference to that, uninsured admission growth of 8.9% represents roughly 2,800 admissions.

And in the third quarter, it was roughly 4,400 admissions. So sequentially, we saw some improvement in there. Going forward, I would anticipate that our uninsured volume growth will track our uninsured ED volume growth.

And right now, I believe kind of as in any change catalyst such as a new state expanding or some other macro trends, I'd anticipate our uninsured volume trends to settle out in the high single-digits. And that's what we have baked into our guidance going forward.

Sam, any other mix comments?.

That's good. Kevin, thank you. Thanks, Bill..

We'll take our next question from Brian Tanquilut at Jefferies..

Hey, guys. This is Jason Plagman on for Brian.

Just a question, in your guidance, have you made any assumptions for benefit from the Louisiana Medicaid expansion?.

Yeah. It's so immaterial in the overall scheme of things. We have – I'm counting up the facilities right now, we have four facilities in Louisiana, and they are not really material with respect to the company's overall position. So it doesn't have any significant impact at all on HCA.

Obviously, it will benefit our Louisiana hospital, but it's not going to be material..

All right. Thank you..

We'll go next to Scott Fidel at Credit Suisse..

Thanks. I had a question just about the rising case mix, and maybe if you can give some more details on what you think the drivers of that are.

And just interested if you're seeing that case mix being moved higher by the exchange volumes or if there's other factors that are driving that?.

All right.

Sam, you want to take that?.

Yeah. The short answer on the exchange volume is no. It's not big enough in the overall scheme of our volume to drive the company's composite case mix. With respect to case mix, again, I'll refer you back to my comments. I mean, the company is very intentional about trying to drive more complex, high acuity-type services to our facilities.

Our strategy, our core strategy within our individual markets is to be able to offer somewhere in the HCA system all services to a patient. So, for example, if we need a transplant, we want to have capabilities at one particular facility where we can offer those kinds of things.

So over the last four years, five years, we've added a significant number of services to our facilities and to our markets that have increased our case mix and increased the overall acuity and built out the capabilities of our provider systems. This past year, we opened up three new burn centers, as an example.

We've opened up probably 10 to 12 new trauma centers. We've expanded our cardiovascular services where we have now 14 to 16 programs TAVR programs, which is very sophisticated procedure for valve surgery.

So those kind of developments are ongoing within the company as part of our core strategy to be able to provide all services, a comprehensive array of services, to our system and to any patient that hits the HCA network..

Yeah. And just a little bit more on that. I mean, what Sam described, these services be it burns or trauma, typically, lead to more surgical procedures in the facility. And as I mentioned in my comments, we've reported seven consecutive quarters of surgical growth. And so as we grow our surgeries, obviously, we're growing our case mix.

And that's showing up in our numbers..

All right. Thank you. Thank you, Scott..

We'll go next to Whit Mayo at Robert Baird..

Hey. Thanks.

Just curious, are you guys expecting any changes with Texas UPL, Florida LIVE (39:59), just any supplemental payment changes for 2016 that we need to be aware of?.

All right, Whit. Bill will take that..

Yeah. Hey, Whit. This is Bill. Right now, no, our Texas waiver program and our guidance anticipates, and we're optimistic that the State and CMS will yield some continuation of the program in the fourth quarter. And so we're not anticipating now material changes to that going forward, nor are we in Florida LIVE (40:27) program right now as well.

So our 2016 guidance for at least the revenue side is fairly consistent with what our 2015 results are..

Thanks, Whit..

Yep..

We'll go next to Sarah James at Wedbush Securities..

Thank you. Guidance looks like it implies about 4.6% to 7% growth in revenue versus the 3% to 7% EBITDA that you talked about. Or if I look at the range of revenue in adjusted EBITDA guidance, it looks like at the low-end, it was accounting for up to 30 basis points of the decline.

So is that just conservatism? And if not, could you walk us through some of the moving pieces that you see going on there?.

For Bill, either....

Well, I mean, I'll try to cover it, and you can add in. I think I get the gist. You're looking at the low-end of our guidance. As Milton said in our comments earlier, the midpoint of our guidance represent on as reported about a 5% growth over our 2015 levels.

When you adjust for the high-tech and share-based comp, the midpoint is roughly 6%, which is one of the higher levels that we've guided going forward. Yeah, on the low-end that would change it from 3% to 4%, but it gets us in that range of kind of 4% to 6% when you factor those items.

Again, Milton mentioned in his comments in response to an earlier question. So I think it from a guidance perspective compared to historically where we've guided, we feel very comfortable with where we stand right now..

Got it.

So on the core business with everything that you're doing with expense control for contract labor and drug costs, you see at least a maintenance of margins if not an improvement?.

Yes. I think that's correct. That's what we're looking for. And as we said, when we get on the high-end of that range, we expect some margin expansion, and in the middle point, it's in margin maintenance mode..

Thank you, Sarah. Thanks, Bill..

We'll take our next question from Ralph Giacobbe at Citi..

Thanks. Good morning. Just want to go back to the cost lines. Again, SWB certainly improved, but looks like a really strong performance on supplies with it down on an adjusted admission basis.

You talked about sort of higher acuity and good surgery numbers, so can you maybe talk about the improvements there, and I guess, the sustainability of that into 2016? Thanks..

Sam?.

Yeah. I think it's important to understand that last year in the fourth quarter our supply costs were uniquely high and actually increased quite a bit more than we had anticipated. I don't remember all the specific reasons when I was looking at the metrics, though, we did jump up sequentially from the third to fourth quarter quite significantly.

And in 2013, we also jumped up, but not nearly as much. This year, we jumped up from the third quarter to the fourth quarter on a per unit basis, but not nearly as much as the fourth quarter last year. So the comp was, I'll say, favorable, if you will, to some degree. We obviously have a very robust supply chain program.

We did see some moderation as Bill mentioned in pharmaceutical costs. And I think that the net of all that yielded pretty much a supply cost metric about where we thought it was going to be inside of our own plan. So there's nothing really other than a difficult comp that I think speaks to supply expense..

Milt?.

Well, I just want to maybe talk about supplies a bit more longer term and some possible upside we have. HPG, our GPO, HealthTrust Purchasing Group, continues to grow. Tenet Healthcare will join HPG in February here in just a few days.

And that should give us some opportunities with respect to further pricing improvement just off our base pricing through HPG contract.

So, on a long-term basis, I think, again, we also have upside just from how we're negotiating our contracts and pricing through the GPO, which, I think, will drive benefits not only for HCA, but really all of our members within HPG over the longer-term over next, say, 12 to 18 months..

Thank you, Ralph.

Thanks..

We'll go next to Gary Lieberman at Wells Fargo..

Good morning. Thanks for taking my question.

Can you talk about your growth in urgent care and how it fits in with the inpatient strategy and if you're starting to see any oversaturation in any markets from urgent care?.

All right.

Sam?.

We have 66 urgent care centers inside of HCA, most of which have come in the form of acquisitions, the acquisition we did in Dallas and the recent acquisition that we did in Las Vegas.

We have developed urgent care centers in Kansas City and Nashville and we have plans to expand our urgent care center platform to other markets and even within existing markets expanded.

There are a lot of urgent care centers inside of HCA markets, but with the acquisition of CareNow in particular, we think we acquired a best-in-class provider and our plan is to replicate that capability in other markets and roll out the model that they've used that is very, very effective for our patients and very, very effective for our network.

As it relates to our network, we do generate downstream referrals from our urgent care centers to both our physicians who are connected to HCA system as well as our emergency room and then on into the inpatient activity.

The volume of downstream referrals is not nearly as large as our freestanding emergency room, which produce a larger downstream flow to our hospitals.

But the components that we're trying to build here between physician clinics, urgent care centers, freestanding emergency room and then hospital-based emergency room is all part of having a system-wide approach to creating convenience, ease of access, user-friendly solutions for our patients, and then building out the geographical footprint of the HCA network..

All right. Thanks..

Gary, thank you..

Thank you..

We'll go next to Chris Rigg at Susquehanna Financial Group..

Good morning. Thanks for taking my question. Just wanted to ask about the trends in the bad debt expense. It's been volatile this year and the seasonal trend from Q3 to Q4, for the first time, that trend has gone – the bad debt's gone down sequentially since 2011. So I was hoping you could give us some color on what you're seeing there.

And then more importantly, when we think about 2016, is sort of this $1.1 million-ish range per quarter the right level to think about? Thanks a lot..

All right.

Bill?.

Yeah, I'll take that. Thanks. As we have reminded people in the past, when you look at bad debts, we think you should look in terms of our total uncompensated care, which includes bad debt, charity and uninsured discounts, because, in any given quarter, you can have some fluctuations in there.

And that's why we give the charity and uninsured discount numbers in my commentary. When you look at uncompensated care, anticipate that to grow as a percent of our gross revenue consistent with what our uninsured growth is.

In the fourth quarter, when I look at uncompensated care, we saw sequential improvement versus the third quarter, and when I look at year-over-year, that year-over-year growth in uncompensated care is tracking our high-single digit uninsured volume growth there.

So, you are subject to some fluctuations in the bad debt line alone as we adjust our uninsured discount percentage, and so you look at uncompensated care in total. But as we look at bad debts, I would think we'd continue to see that in play at our high-single digit uninsured volume growth..

Chris, thanks..

Thanks..

Thank you..

We'll move next to John Ransom at Raymond James..

Hi. Good morning. I think your story is pretty straight forward. My question is, is there anything that would tempt you off your current path? You haven't really made a big acquisition in a while.

Is there anything other than a big market coming up for sale that you're now thinking about? And then secondly, are there any plans, in my lifetime, to provide any more color on Parallon as a separate entity? Thank you..

Hey, John, how long you're going to live here?.

Let me take this..

I'll let Milt take this..

The Parallon first, we don't see Parallon as a separate entity. And actually when we formed Parallon, we really wanted it to be a subsidiary within HCA that we could grow. And we still have that objective and Parallon is growing. I mentioned HPG earlier, solid growth in HPG and I think we'll continue to see that as well.

With respect to your first question around acquisition opportunities, we have the financial flexibility, as you know, and access to capital to do more significant acquisitions. We're very disciplined in the sort of markets and facilities that we want to invest in. If it's just a matter of course of owning more hospitals, we could do that.

But, again, they wouldn't fit our profile, wouldn't fit the long-term growth prospects and return prospects that we're looking for. So, we have been very disciplined in that and we will continue to be disciplined. That being said, we pretty much at any point in time, we have a pipeline of meaningful opportunities. As I said....

Well, you never buy anything though, so..

No, I was going to say you heard me say many times over recent....

Your M&A guys have to be getting bored. They keep bringing the deals and you guys never buy anything..

Of course, we do a lot of in-market acquisitions. But as far as the big ones you're speaking to, things like say Kansas City that happened in 2003, those opportunities are really hard to find. They're going to come out of the not-for-profit sector.

And typically, we may engage in conversation, but many times, these organizations decide ultimately not to sell. So, we'll continue to be active and looking for the right opportunities. But, again, we're not building any of those into our expectations here in the short-term. But then again, if we find the right one, we're prepared to move on it.

We've got the balance sheet and capability to do it. And we'll continue to be active in pursuing them, again, if the right markets present themselves..

Let me add one thing to Milton's comment about in-market acquisitions. Just over this past year, we acquired a physician network in San Jose, which significantly solidified our position strategy in a very important and growing market to HCA.

We bought a large urgent care center inside of Las Vegas, which significantly improved our access and physician relationships and so forth in that market, which is a very important market to HCA. We bought a rural hospital that was contiguous to Orlando and Jacksonville.

We were able to re-channel referrals out of that hospital into HCA's system, pick up incremental market share. So, these complementary acquisitions, on top of that, I think we acquired five ambulatory surgery centers this past year and added it to our network within a couple of major markets.

So these things are very, very strategic and create more durability, more competitiveness, and allow us to grow organically in very high growth markets. So, those are conservative from a capital allocation standpoint, predictable from a returns standpoint, and provide a lot of synergies to the organization.

And so from that standpoint, those are very, very important. We don't call them out that often, but they're very, very important to those individual markets..

John, thank you very much..

All right. Thank you..

We'll go next to Matthew Borsch at Goldman Sachs..

Yes. Hi. Good morning. Just wondering if you can talk about, within bad debt, the portion that relates to insured patient cost sharing and maybe how you saw that trend this year and as a percentage of the bad debt mix, and where you think that's going..

All right. Matt, thank you.

Bill, you want to get that?.

Yeah. Matt, thank you. Historically and pretty much consistent this year, about 30% of our bad debt is associated with kind of the deductible and copay and 70% coming from the uninsured population.

When I look at kind of our deductible and copay and patient liability, really, what we've seen throughout 2015, we're seeing those kind of average balances grow in that 10% to 11% level, where maybe historically they were growing in that 7% to 8%. So, the average balances are growing a little bit.

Our collections are holding – so our collections per account are holding with what are historical levels. So, it is slightly contributing to some increase in bad debt, but the majority of the bad debt's being driven by uninsured activity that we have..

All right. Thanks, Bill..

Thanks, Matt..

We'll go next to Ana Gupte at Leerink Partners..

Yeah. Thanks. Good morning. I wanted to follow up on the question about the bad debt as it relates to the health insurance exchanges.

The plans are – generally, the public plans are saying it's about 30% of their membership is special enrollments and, generally speaking, the special enrollment people are incurring, I think, 25% to 55% higher claims costs.

And I was wondering, as you saw in the third quarter, the uptick in the bad debt, you talked about the Medicaid delays in processing, but a piece of it, I think, was exchange related.

And in the fourth quarter, as these guys probably saw the deductibles run through, do you have any idea of what their utilization patterns have been? And if they end up being delinquent between the fourth quarter and the first quarter, if your claims adjudication has already been able to identify that, are you talking to – or are your claims systems on reimbursement communicating with the plans to make sure that's not happening?.

All right. Ana, thanks.

Bill?.

Well, first, put in perspective that our exchange volume is roughly 2% of the total company volume. So the exchange activity by itself is relatively small going forward on that. So, as we look at kind of the activity within the exchanges, we did mention in the third quarter we were seeing some previous exchange volume move to uninsured.

It was 400 admissions for HCA in the third quarter. It was roughly the same in the fourth. That's on 460,000 admissions for the company. So, yeah, there is some activity in that area. But for HCA, it's immaterial for us. And it's contained within the overall aspect of our bad debt trends that I've talked about previously..

All right. Bill, thanks. We've got time just for a couple more quick ones here..

And we'll go next to Josh Raskin at Barclays..

Thanks. Good morning. Just wanted to follow up on the CapEx numbers. I know you guys outlined the increase earlier this year and talking about $2.7 billion.

So, just curious how much of that is maintenance CapEx? And then maybe you can give us a little bit of color on how much is being spent on traditional acute care hospitals versus outpatient centers and other things, or maybe just more color on those expenditures..

All right. Thanks, Josh.

Sam?.

We spend about $250 million a year in IT-related expenditures. So I'm going to just lay that out there. Then, about $1 billion of our spend is what I would call routine kind of investments.

So, then you've got roughly $1 billion to $1.2 billion that's related to growth prospects, capacity constraints, new service line development, outpatient facilities and so forth. As I mentioned in my comments, the investments that we've been making are producing about 1,000 new beds over the course of 2016 and 2017.

That's slightly up over the number of beds that we put into service in 2014 and 2015 and slightly up over 2012 and 2013. We have a number of markets that are approaching capacity and they're very significant markets to HCA.

And a lot of this capital is going specifically to these markets that are at a certain level of capacity, inpatient capacity, outpatient capacity, primarily in our ERs, or surgical capacity. And so, it's very well diversified both in service line capability and also within our market. So, it's being shared very broadly across the company.

Again, we think this diversified approach to different kind of service allocations and market allocation creates a very conservative return profile for HCA.

The more we can put it on an existing chassis, where we have physicians, we have fixed costs, we have a reputation in the market, the easier it is to produce a return because we're able to leverage those existing capabilities. So that's our fundamental approach. We do have a few markets where we're adding new facilities like new hospitals.

They're more low startup hospitals that are very important to geographical presence and also to network development. But those don't add a lot of volume, but they do create new relationships. And over the long pull, we think they'll be very significant facilities to our markets..

All right. Bill, did you want to add....

Yeah, I'd just say with our increase in capital spend, and Sam and I, along with our group presidents are spending time out in the field within our hospitals. And from that we see opportunities, opportunities to invest, as Sam said, to expand services or to deal with capacity constraints that would otherwise exist.

And it is a conservative investment strategy versus an acquisition for the reason Sam just noted. And just, I guess, to back up our performance, if you look back two years ago, our return on invested capital was 14.1%. And that's an incredibly – I think incredible number to start with.

But based on the 12 months ended December 2015, our return on invested capital is 15.4%. So, if we're investing more capital in our existing market, we're seeing a return growth. And so, again, we like the strategy. That's why we expanded it towards the – over the three years to $7.7 billion, up about $0.5 billion.

And again, it gives us confidence with our guidance to see these opportunities in the fast-growing markets..

All right. Thanks, Josh. Two more questions..

We'll go next to Gary Taylor with JPMorgan..

Hi. Good morning. The reality is you've answered most of my questions. So I won't....

All right.

Next?.

I'll let you....

Sorry..

Thank you..

Go ahead, we'll let you.

Do you have one?.

No, I was just going to say, go ahead and take the last one. You've answered really my substant question, so I don't want to hold you up..

Thank you very much. Appreciate it..

Thanks, Gary..

All right..

And we'll take our last question from Paula Torch at Avondale Partners..

Well, thanks, guys, and, Gary, for squeezing me in. I'll just end with a quick question, I think, maybe on market share. So, I was wondering if you might just give us a little bit of an idea of how much more room is left to gain market share in your market or how much of an uptick you can get longer-term in market share? Thanks..

Sam, you want to close with that ne?.

Well, we're running 24.5% market share across all of HCA's market. So, I'd like to think we have 75 percentage points of upside. No, I'm being facetious there, Paula. We've been on a pattern of growing like I said between 25 basis points and 40 basis points a year. My thinking is for 2016 in particular and I think that's a reasonable target for us.

The thing about HCA is we compete in a very fragmented sort of environment, where the same competitor doesn't really exist from one market to the other. So, what we compete against in Miami is not necessarily the same system that we compete against in Dallas, nor is that the same system that we compete against in Salt Lake City or even San Jose.

So that fragmentation allows us to, I think, have advantage in the market.

And when we can deploy capital in a very unique way or effective way or create a service line capability or move some other initiative across HCA's markets, we're able to do that maybe without our competitors being able to see it like we are able to see it because of our multi-market perspective.

So from a market share standpoint, I think that's a pretty good metric for the company as far as the type of growth that we're thinking about, and I don't see any reason why that's not doable for the company in the near term..

Okay. Thank you..

All right. Paula, thank you. We thank all of you and look forward to hearing from you. Have a great day..

And that does conclude today's conference. Again, thank you for your participation..