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

Whit Mayo - Robert W. Baird A. J.

Rice - UBS Kevin Fischbeck - Bank of America Matthew Borsch - Goldman Sachs Justin Lake - Wolfe Research Josh Raskin - Barclays Brian Tanquilut - Jefferies Ralph Giacobbe - Citi Sheryl Skolnick - Mizuho Securities Gary Lieberman - Wells Fargo John Ransom - Raymond James Scott Fidel - Credit Suisse Gary Taylor - JPMorgan Paula Torch - Avondale Partners.

Good day everyone and welcome to today’s HCA Fourth Quarter 2016 Earnings Conference. Just a reminder that today's call is being recorded and for opening remarks and introductions, I would like to turn the call over to the Senior Vice President, Mr. Vic Campbell. Please go ahead, sir..

All right, Laurie. Thank you and good morning, everyone. Mark Kimbrough, our Chief Investor Relations Officer, and I would like to welcome all of you on today's call including those of you on the webcast.

Here this morning as usual, our Chairman and CEO, Milton Johnson; Sam Hazan, President and Chief Operating Officer; and Bill Rutherford, CFO and Executive Vice President. 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 expectations.

Numerous risks, uncertainties, and other factors may cause annual results to differ materially from those that might be expressed today. Many of these factors are listed in today's press release and 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 statements 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 or gains on sales of facilities, losses on retirement of debt and legal claims cost 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 fourth quarter earnings release.

This morning’s call is being recorded as you know and a replay is available later today. With that, I’ll turn the call over to Milton..

All right, thank you, Vic, and good morning each of you joining us on the call and the webcast this morning. Now this morning we issued our fourth quarter and full year 2016 earnings release. The release is consistent with the preview we issued on the 9th of January.

I’ll make a few comments on the quarter and the year and then turn the call over to Bill and Sam to provide more detail on the quarter and 2017 guidance. We finished the year on a solid note with fourth quarter adjusted EBITDA totalling $2.206 [ph] billion a record quarter for adjusted EBITDA, exceeding our industry as adjusted EBITDA by 3.6%.

For the year, we reported adjusted EBITDA about $8.216 billion up 3.8% over 2015. For the full year 2016 diluted earnings per share excluding gains and losses of sale facilities and losses on retirement of debt, and legal claim calls, benefit cost increased 23.6% over full year 2015.

2016 was the year in which we performed well and light of just for comparisons to prior year growth performance. We executed our growth agenda effectively in 2016 as we continued our focus on adding access points to our network, broadening service line capabilities and expanding debt in clinical service offerings.

Our growth agenda has delivered consistent performance. In fact, to illustrate the company has reported same facility admission and adjusted admissions growth for nine consecutive years, ER visit growth for 10 consecutive years and surgical growth for three consecutive years.

We believe our strategies will continue to be effective and position us well for the future. WE believe investing capital in our existing markets is the key component of our growth strategy. In 2016, we invested $2.76 billion in capital expenditures for expansion of services and capacity in our large fast growing urban markets.

And as you may have noted in our guidance issued this morning we expect to invest approximately $2.9 billion in 2017. Moving to cash flow, we generated $5.65 billion of cash flow from operating activities in 2016, up 19.4% over 2015.

In 2016, as Bruce will mention we invested $2.7 billion in capital expenditures, we distributed $434 million to non-controlling parties producing free cash flow of approximately $2.5 billion.

We returned $2.75 billion to shareholders in the form of share repurchases which resulted in HCA repurchasing about 36.3 million shares of our stock or approximately 9% of our outstanding shares since the beginning of 2016. On this subject of capital allocation, the company has not paid a regular dividend since its IPO here in 2011.

And we have decided to maintain our current policy on dividend payouts. Although we remained confident in our long term growth prospects, we believe its’ prudent to take conservative approach and maintain maximum financial flexibility until we gain greater clarity of health and tax policies at the federal levels.

Today, we believe share repurchase is the appropriate means to return free cash flow to shareholders, but we will continue to evaluate our policy overtime. I’d like to take a moment to comment on our recent settlement with the Healthcare foundation of Kansas City.

The Missouri Court of Appeals recently reversed key parts of an earlier court's decision and confirmed that we spent in excess of $450 million during the five year term following our acquisition of the health Midwest Health system in 2030.

While we disagree with the remainder of the Court ruling, we felt it was best to end this long standing dispute and we have entered into a final resolution agreement with the healthcare foundation of Kansas City.

In the 14 year since our acquisition at Kansas City, we have invested over $1 billion in the market to expand and upgrade our facilities and add new services, and I’m very proud of the work we have done in Kansas City. I’m proud of the settlements and based on earlier court’s decision, the company had reported liability of $478 million.

This settlement of $188 million brings a final resolution to this dispute and allows us to continue our focus on caring for the Kansas City community. I’ll close my comments with my thoughts on our 2017 guidance included in our release this morning.

With respect to adjusted EBITDA growth, our guidance yield was approximately 2.5% to 6% growth for 2017. Our guidance reflects continued volume growth, reasonable pricing and well managed expense growth. I am looking forward to 2017 and I believe the company is well positioned to achieve its goals for the year.

And with that, I’ll turn the call over to Bill..

Great. Thank you, Milton, and good morning, everyone. I will cover some additional information relating to the fourth quarter results and review our 2017 guidance and I’ll turn the call over to Sam for some comments on our operations. As Milton commented we are pleased with the quarter’s results.

Fourth quarter was a difficult comp for us with a strong result we had in Q4 of 2015. However, our extensive management helped to deliver another good quarter and solid performance for the year. For the quarter, adjusted EBITDA increased 3.6% to $2.206 billion to $2.131 billion last year.

Adjusted EBITDA margin in the quarter was 20.7% versus 20.8% last year. In the fourth quarter, our same facility admissions increased 1.6% over the prior year and equivalent admissions increased 1.5%. During the fourth quarter, same facility Medicare Admissions and equivalent admissions increased 2.7% and 3% respectively.

This equates both traditional and Managed Medicare. Managed Medicare admissions increased 5.3% on a same facility basis and represents 33.6% of our total Medicare admissions. Same facility Medicaid admissions and equivalent admissions increased 3.1% and 3% respectively in the quarter, consistent with recent trends.

Same facility self-pay and charity admissions declined 0.3% in the quarter, representing 7.6% of our total admissions, compared with a 7.7% last year. Managed care another which included exchange admissions declined 0.4% and equivalent admissions were essentially flat on a same facility basis in the fourth quarter compared to the prior year.

Same facility emergency room visits increased 1.6% in the fourth quarter compared to last year. Same facility self-pay and charity ER visits represented19.3% of our total ER visits in the quarter slightly lower than the prior year.

Intensity of service or acuity continued to increase in the quarter with our same facility case mix increasing 3.3% compared to the prior year period. Same facility in patient surgeries increased 1.4% and outpatient surgeries declined 0.6% from the prior years. Same facility revenue per equivalent admission increase 1.9% in the quarter.

Same facility managed care and other revenue per equivalent admission increased 5.5% in the quarter which is treated consistent with our recent trends. Same facility managed care and other case mix increased 3.4% compared to last year. Same facility charity care and uninsured discounts increased $660 million in the quarter compared to the prior year.

Same facility charity care discounts totaled $1.047 billion in the quarter, an increase of $82 million from the prior year period while same facility uninsured discounts totaled $3.469 billion, an increase of $578 million over the prior year.

Same facility operating expense per equivalent admission increased 2.8% compared to last year's fourth quarter. Salaries and benefits as a percent of revenue were down slightly to 44.8% compared to the 44.9% in last year’s fourth quarter.

Same facility supply expense per equivalent admission increased 5.3% for the fourth quarter compared to the prior year, this increase was primarily driven by growth in medical device expanded increased volume and some higher acuity services such as [Indiscernible] procedures, neurological cases and orthopaedics.

Other operating expenses include 30 basis points in the last year’s fourth quarter a 17.7% of revenue mix. Let me touch briefly on health reform activity in the quarter. In the fourth quarter of 2016, we saw approximately 12,300 same facility exchange admissions as compared to 11,300 in the fourth quarter of last year.

For full year of 2016 our health exchange admissions increased approximately 15% over 2015 levels and represented about 2.7% of total admissions.

We saw about 43,900 same facility exchange ER visits in the fourth quarter compared to 38,000 in the fourth quarter of 2015.For full year 2016 health exchange ER visits increased 23% and represented 2.4% of total ER visits. All-in-all health reform activity was generally in line with our expectations.

As reported earnings per share for full year 2016 was $7.30 as compared to $4.99 in the prior year.

2016 earnings per share includes positive benefits of $0.39 to the Kansas City legal settlement, $0.41 to the effect of the adoption of new accounting standard related to the tax benefits for equity awards and $0.13 to the completion of federal tax audits for 2011 and 2012. Let me touch briefly on cash flow.

The strength of our cash flow and the disappointment of balanced approach to capital allocation remains an important advantage for the company. In the fourth quarter, cash flow from operations was $1.699 billion compared to $1.558 billion last year.

For the full year 2016 cash flow from operations was $5.65 billion up over $900 million from the $4.73 billion last year. As we mentioned throughout the year cash flow from operations includes approximately $160 million for the full year of 2016 from our adoption of the accounting standard on reporting the tax benefits related to equity awards.

After adjusting for this accounting change, cash from operations increased approximately $740 million or just over 15%. In addition, cash flow from operations included an improvement in net AR day’s decrease of 53 last year to 50 at December 31st 2016.

Capital spending for the year increased to $2.76 billion from $2.375 billion in 2015 as we continue to invest in long term growth opportunities for the company. Free cash flow for 2016 was $2.459 billion a $595 million increase or 32% over $1.864 billion in 2015 and as a note of mention we completed $2.75 billion of share repurchases during the year.

We had approximately $1.85 billion remaining on our $2 billion authorisation as of December 31, 2016. At the end of the quarter, we had approximately $2.1 billion available under our revolving credit facilities and our debt to EBITDA ratio was 3.8 times. Also it is important to highlight this activity through our capital market transactions.

Over the past couple of years we’ve reduced our weighted average interest cost to approximately 5.3% at December 31. Our return on invested capital was approximately 16.6% as of the end of the year.

These cash flow and balance sheet metrics highlight an important key string for the company and allows us to continue to invest for long term growth, distributing value to our share repurchase program, maintain ample liquidity and maintain our leverage ratio towards a lower end of our stated range, all of this positions us very well going into 2017.

So with that, I’ll move into a discussion about our 2017 guidance. Highlighted in our earnings release this morning, we estimate our 2017 consolidated revenues should range from $43 billion to $44 billion. We expect adjusted EBITDA to be between $8.4 billion and $8.7 billion.

Within our revenue estimates, we estimate equivalent admissions growth to range between 2% and 3% for the year, and the revenue for equivalent admissions growth to range between 2% and 3% for 2017.

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

Medicaid revenues for accrual mission are estimated flat year-over-year and manage and commercial revenues per equivalent admission are estimated to grow between 4% and 5%. We also anticipate grow and share based compensation of approximately $40 million and the anticipate operating expenses per adjusted admission growth of approximately 2.5%.

Relative to health reform, we do expect some modest growth in health exchange volumes, but isolating the net EBITDA impact to health reform from core operations that are becoming more subjective and increasingly difficult.

We will continue to report on exchange volume which we can identify, but converting these variables to an EBITDA impact has a lot of increase in this fourth year of reform. As an overall summary, we believe reform contribution in 2017 will be materially equivalent to what the contribution we experienced was in 2016.

Relative to other aspects of our guidance we anticipate capital spending of $2.9 billion in 2017 as we see continued opportunities to invest in our markets and support a key strategic initiative. We estimate depreciation and amortization to be approximately $2.05 billion and interest expense to be approximately 1.7 billion.

Our effective tax rate is expected to be approximately 34%. And lastly, our average diluted shares are projected to be approximately 376.5 million shares for the year and earnings per diluted guidance for 2017 is between $7.20 to $7.60.

Earnings per diluted share guidance includes an estimated 150 million income tax benefit, or $0.40 per diluted share, related to the accounting standard on recording excess tax benefits related to equity award, but does that not include losses or gains on sale facilities, losses on retirement of debt, a legal claim costs.

So, that concludes my remarks and I’ll turn the call over to Sam for some additional..

Good morning. Let me began by giving you some of the volume stats that are normally provide on these calls. Once again in both the quarter and the year the company had broad-based volume growth across our market and across most of the facilities in service lines that make up our business.

For domestic operations on a same facility basis, eleven of 14 divisions had growth in admissions in both the quarter and in the year. Non-division had growth in adjusted admissions in the quarter and 13 divisions had growth in the year. 10 divisions had emergency room visits growth in the quarter.

Free standing emergency room visits grew 11% and accounted for approximately 60% of our overall ER growth in the quarter. Hospital based emergency room visits grew 0.7% in the quarter. In the year 13 divisions had emergency room visits growth.

Inpatients surgeries grew 1.7% in the quarter, surgical admissions were 28.1% of total admissions in the quarter. Inpatient surgical volumes were particularly strong again this quarter in cardiovascular orthopaedics and neurosurgery categories. For the year surgical admissions were 28.3% of total which is an increase over the prior year.

10 divisions had inpatient surgeries growth in the year. Outpatient surgeries were slightly down in the quarter about 0.6%, hospital-based outpatient surgical volumes decline 0.5% and volumes decline 0.7% in our free standing ambulatory surgery division. Seven of our divisions in a quarter had growth in outpatient surgery volume.

In the divisions that were down multiple service lines accounted for the decline. For the year, outpatient surgeries grew 1.2% with a 11 divisions showing growth. Behavioral health admissions grew 0.8% in the quarter and 2.2% in the year. Rehab admissions grew 5% in the quarter and 3.3% in the year.

Deliveries were down 1.8% in the quarter and down 1% in the year. Again most of these declines were in Medicaid payers. Neonatal admissions increased 0.5% in the both the quarter and the year. Cardiology procedures grew 4.7% which is generally consistent with the growth rate for the year.

Trauma volumes grew 18% in both the quarter and the year, observations visits were up 2.7% in the quarter and it grew 7% in the year. All-in-all the fourth quarter in 2016 were solid periods of growth for the company and they continue to show as Milton said a consistent pattern of growth over many years.

We believe our strong portfolio of markets and favorable trends within them should yield overall demand growth in the range of 2% to 2.5% per year over the next few years.

Our approach to these markets remains the same as we strive to be the provider system of choice for patients and physicians, the improvements we have made in clinical and operational metrics coupled with our increasing capital spending position the company well from a competitive position and should provides the solid growth prospect in the future.

The company has over $4.5 billion of capital in-flight that is just to hit our markets.

This in-flight capital which is approved project that are not yet in service and should be completed over the next three years will add urgent care centers and free standing emergency links to our provider systems allowing us to improve patient access and experience with more conveniently located facilities.

Additionally, it will increase capacity in existing hospitals by adding more inpatient beds, emergency room beds and operating suites thus relieving constraints in many situations.

And lastly, it will enhance service line offerings with new equipment in clinical technology which will provide a better environment for nurses and physicians in delivering care to our patients.

In addition to capital spending our growth agenda includes coordinated marketing strategy, patient care coordination systems and multiple human resource programs that are particularly focused on physician developments and nursing operations.

This agenda is supported by strong execution systems and resource by the unique scale and operational capabilities of HCA.

In sum, we believe we continue to have solid growth opportunities across our diversified portfolio of market and services lines and we believe our local provider systems are well-positioned to capitalized on these opportunities in the future. With that, let me turn the call back to Vic..

Thank you, Simone, Samuel and Milton. Lori, if you come back on and poll for questions, and as we always do I’m encourage each of you that limit yourself for one question and if you got a second jump back in the queue..

Thank you, sir. [Operator Instructions] And we will go first to Whit Mayo of Robert W. Baird..

Hey, thanks. Maybe just to start with that last point, Sam, if you could perhaps elaborate a bit more on some of the certain, the capital priorities for 2017 or maybe just broadly the $4.5 billion of in-flight capital that you referenced.

Is there anything that's for unique or different this year versus the prior-year or third any specific larger project that we should be aware of and then maybe if you could just comment quickly on just the cash flow expectations for 2017? Thanks..

With respect to the capital spending plan for the company with, for the most part, there aren't any significant changes in our approach to capital spending. We believe the company has growth prospects in many of our markets.

We've been investing to take advantage of those growth prospects by expanding like I said our networks where we're adding facilities and so forth. And then at the same time, we have a number of facilities that are operating at unusually high occupancy levels, forcing us to address certain capacity constraints.

When you look at our capital spending, that we report in our cash flow statement, some of that capital is being spent but it takes a while for these projects to come online and that's why wanted to give you a sense of what's in the pipeline for the company because we have been accelerating our capital spending.

And as this capital starts to come unwind more in 2017 and 2018, then it is coming online in 2016 and 2015 we're expected to at roughly 1% to 1.5% to our bed capacity on the inpatient side, roughly 4% to 4.5% on our emergency room side. And we think those are important component of our overall growth strategy.

We spent about $250 million a year on our key capital. We spent about $1.5 billion on routine related capital and in the balance tends to be more strategic addressing these growth prospects and addressing some of these capacity constraints. No bolus is unusually going to one market or the other, so it’s diversified from the standpoint of market.

It's further diversified from the standpoint of facilities within those markets and then from a service line standpoint, I would submit that it's quite diversified as well, and we think this is a very conservative deployment approach. It's very effective in resourcing our growth agenda is across the company.

And we're optimistic that it's going to yields value for the company over time. And then at the same time we have a number of facilities that are operating at unusually high occupancy levels forcing us to address certain capacity constraints.

When you look at our capital spending that report in our cash flow statement, some of that capital is being fit, but it takes a while for these projects to come on line and that’s why I wanted to give you a sense of what’s in the pipeline for the company because we have been accelerating our capital spending and as this capital starts to come in online more in 2017 and 2018 then it is coming online is 2016 and 2015, we’re expecting to add roughly1 to 1.5% of our bad capacity on the impatient side roughly 4% t 4.5% on our emergency room side and we think those are important components of our overall growth strategy.

We spend about $250 million a year on our key capital. We spend about $1.5 billion on routine related capital and in the balance tense to be more strategic addressing these growth prospects and they’re addressing some of these capacity constraints.

No – is unusually go into one market or the other, so its diversified from a standpoint of markets, its further diversified from the standpoint of facilities within those markets and then from a service line standpoint I would submit that its quite diversified as well and we think this is a very conservative deployment approach, its very effective in resourcing our growth agenda across the company and we’re optimistic that its going to yield value for the company over time..

Yeah. We’re on cash flow. We anticipating cash flow from operations to range somewhere between 5.3 and 5.5 billion, will be down slightly from this year due to the some anticipated increase in cash taxes..

Got you..

What Sam said about increase just to frame it, I'm looking here, it's a two-year period in 2012 and 2013. We added about 800 inpatient beds during that two-year window and 2014, 2015 to your window we added about 900 new beds inpatient beds and for 2016, 2017 two-year period, there be almost 1000.

So as Sam was saying is increasing the amount capital coming on my way expect that to grow, we’ll make about 2017, 2018 as well..

All right. Thank you, Vic..

And moving next to A. J. Rice at UBS..

Thanks, hi, everybody. I'm going to try to squeeze in two here real quick, if I could. One, obviously there's been a lot of focus on the repeal-and-replace discussion. But there's other things that are in the works, too, one of which is the repatriation potentially. You guys have been overseas, in London in particular, for a long period of time.

Do you have any significant cash that you might consider bringing back if there is a holiday? And then my strategic question was, in the last couple of years we've seen payers get involved in purchasing physicians, then they moved to urgent care centers, and now very recently there's been this move to ASC markets.

Any thoughts about that? Has that changed the competitive landscape? Has it changed anything that you want to do or just business as usual? Any response to that new competitive evolution?.

All right. Hey, A.J, let me let Bill to take the first piece on the repatriation, maybe Sam add some comments on/.

A.J. real quick on the cash overseas. We have had London international operations. We have approximately $400 million cash overseas that if there's an opportunity that would give us some opportunity to repatriate that, so we’ll just wait to see how certain tax policies may unfold to see how we deal with that progress.

Okay..

A.J. what’s your second question about payers…..

Payers getting into the providers base..

Well, there’s has been significant movement across our markets where payers entering the provider space. Optum and United have made a couple of strategic acquisitions, but they’re sprinkled from one market to the other and they don’t really have what I call it concentrated influence on any one particular market.

Obviously, we see opportunities for us to work with the payers as they try to build out providers assistance because what we’re doing as an organization and we’re having discussions with the payers around using our network and our footprint in these areas to accommodate their objectives and we think there’s a lot of opportunities there for HCA and other payers to accomplish that.

But we’re not seeing any significant competitive dynamics to-date nor we see it in the foreseeable future coming from those strategic move across the markets, again, within a particular market there could be a bit of concentration around that, but we had some of those situations in the past in markets already and we seem to be able to work with the payers or around the payers in those emphasis to accomplish what we need to get down in those individual market..

Thank you..

And we’ll go next to Kevin Fischbeck of Bank of America..

Great. Just wanted to understand the comments around capital deployment, you mentioned, both wanting to understand the impacts to the healthcare regulatory environment as well as the tax policy.

Which one is more of a driver, in your view? And when you think about the impacts on healthcare, is there an expectation that there may be an acceleration in deals going forward if things do change for the worse? Would you expect the M&A to be a bigger part of this or would you still expect, for the most part, your share purchase to be the biggest use of excess free cash flow.

Kevin, thank you. Milton, do you want to….

Yes. And Kevin, it’s Milton.

You’re asking which one I guess its most important for emphasis health policy changes or tax changes and with respect to our decision around dividend payment, I’d say its equally driven, right now we need to understand how our dividends be tax in the future versus share repurchase opportunities and so you know, we’ll like to have some more clarity around that before we make the decision on a dividend and have a fixed charge on the company.

Obviously health policy is something we’re concern about is well, and we’re following very closely in Washington. So, I can’t really, necessarily rank them because they’re both important into the decision around the dividend. I think with respect to opportunities for acquisitions in this environment, we do have a pipeline today, I’ll comment.

I will comment that I think, I will also say as usual, its very difficult to know how some of the opportunities and discussions we’re having will actually turn out, but I will say that the pipeline today is little more robust than it has been in recent years and the transactions feel like they could be more realizeable and that’s just my kind of feel for the market right now.

So, that’s a piece of it, but with our strong cash flow that we have and strong balance sheet, I feel like we’ve got the ability to remain active with the share repurchase program and to be acquisitive. So I don’t see a trade off there, but we would like as I said in my comments, we want to remain at this point conservative with our approach.

We won’t maximum financial flexibility for the company to be able to take advantage with opportunities that could come in the coming few months or few years. So, we will as I said in my comments consider to evaluate our policy around dividends going forward is just in the current environment.

We’d like to have more clarity before make any decision, that’s really a permanent decision with respect to the company’s use of cash..

Kevin, thank you..

And we’ll go next to Matthew Borsch at Goldman Sachs. .

Yes, just a question, as you think about potential tax reform in particular, are you trying to get EPS to be the primary earnings metric that investors look at? And is that something that you've found investors are more receptive to as compared to a few years ago?.

Matthew, this is Milton and Bill maybe jump in, but we definitely believe that investor should be looking at EPS. We have been a consistent repurchaser of our stock. We believe we’ve create lot of value for our shareholders since the IPO.

I don’t have number top of head, but billions of dollar maybe approaching not to $10 billion of share repurchase since the IPO. So we think that’s a very effective way also very tax effective way to return cash to shareholders and of course this does results in higher growth in EPS.

So it is something we will like to investors to focus on with our current strategy. We think it’s a low risk, late to return cash and create value for our shareholders and so we definitely think that it should be metric that our investors should be paying more attention to..

Thank you, Matt..

And moving next to Justin Lake at Wolfe Research..

Thanks, good morning. Just wanted to ask one clarification and jump off my question. Sam you said 1.5% growth in patient beds and 4% growth in capacity. Is that annual number and over what period of the day. Just want to confirm..

It is an annual number. That’s on average, I mean, we have about 38,000 impatient beds that are operational, so the 400 or so that Milton counted, it’s a 1% increase in capacity and then our ER beds we have about 5,000 ER beds so if we’re adding 200 – 150 to 200 then next we’d get to the 4%.

Its important to understand that our impatient bed occupancy for the company is at record highs, we’re operating over 70% in patient occupancy utilization on our operating beds. Our emergency room room that utilization is running almost 90% utilization.

Again those constraints create some challenge for us in many facilities until our capital can get there. So that's where the numbers come from, Justin. Those are some of the metrics underneath that, and that's how we are thinking about the roll forward there. .

All right. Now we will get to your [ph] questions. .

And moving next to Josh Raskin at Barclays..

Hi, thanks. Just a question around the outpatient services trend, there maybe specifically ASC volumes with outpatient surgery actually take negative.

I am curious if there is something going on, I mean anything that you can point to that would be a change, you think there is now saturation of facilities as there is too much competition, or is it just a one quarter doesn’t make a trend and we will see later?.

In general I think it's more of the later than anything else. There hasn’t been a significant amount of new supply Ambulatory Surgery Centres across our markets.

We do have some under this movement our physicians from centre to the other that sort of typical we've had pretty good growth of trend and are able to towards surgery centre division, as well as our hospital based outpatient units over the past few years, but the last two quarters has been a little softer than we anticipated.

We do have had company's division showing growth in an half that are down with a variety of reasons driving some of the declines in some of the markets. I was still bullish on both components of our outpatient surgical initiatives.

We are investing in capacity in those areas in some markets, we are adding technology and others, and we continue to work with physician to create the environment that they want for their patients. And I anticipate that we will be a back to our normal growth period, our growth trend over the coming periods..

I just agree with what Sam telling and I am looking here at our freestanding outpatient surgery growth each quarters. This is the first quarter we had negative growth in the line of 8 [ph] to Sam's. So we have been very consistent growth around, one just under 3% and first quarter of 2016 the manufacturing growth was 5%.

So it's been a consistent grower for us. This is the first quarter that we had we reported negative growth in freestanding outpatient surgery next quarter. .

Thank you, Josh..

And we will go next to Jefferies with Brian Tanquilut..

Hey, good morning, guys.

Milton, as we think about the ACA obviously a lot of unknowns there, but where guys were sitting right after the election? What's the view or what was the decision internally in terms of like the Plan D [ph] as we think about the potential [Inaudible] appealed in terms of dedication and driving growth going forward?.

I don’t know think that as we go -- of course lot of uncertainty with respect to our customers that I think what we feel replacement [ph]. I do believe when I think the management team here believe that there will be -- if there is a retail there will be a replacement.

What that replacement will look like and how many lives it'll cover, it's been a -- we can't, we don’t know. But I'll say I don’t see it's going back up to the 2024 sort of uninsured volume lies and percentage is population uninsured that we had in 2014.

So we had a long history of Brian of being able to react to the market place and to deal with changes in healthcare policy and this is one of the work through I am confident of that. And so I don’t see today any sort of changes and I think we have articulated that in our call this morning changes in our operations and our strategy around operations.

We are moving forward. We are investing capital. We continue to see demand up in our markets. The exchange business is important to us, but it yet it only as about 2.5% of extra little volume. So we watched the market place very, very closely and to be able react to it when we see change coming.

And this is one of the situations we are going to continue to do that. This next year we will be watching the market very closely as we get more clarity around how we think health policy changes if any in the next two, three years it will impact ACA.

We will be very clear and articulating that to our investors and trying to quantify any potential impact. But today we remain very optimistic with our guidance for 2017 and then we will have to see how things work out later in the year. .

All right. Thanks, Brian..

And we will move on to Ralph Giacobbe at Citi..

Ralph Giacobbe:.

. :.

The market share data that we have, which is most current is through the second quarter of 2016. Our overall market share is flat. So we have seen some pressures on our overall market share where we are flat at around 25% for that 12 months, period ending second quarter of 2016. I think there are two issues for overall market share being flat.

One, we have seen increased competition as I have mentioned in the past in the form of new facilities in a lot of our markets both on the in patient side and the outpatient side and we can point to that as a fairly significant contributor to some of the pressure.

And then the second point which cause right back into our capital discussion as we do have significant capacity constraints in a number of our facilities that are poised for growth. I understand we get this capital along, we think that will open up some market share opportunities for the company.

On a commercial side, we have seen a little bit of drop in our market share, it's isolated to a handful of markets, but they happened to be big commercial markets for ACA where we've seen an accelerated level of competition in some of these suburban markets where there is density of commercial lot.

We have what we think our responsible strategies for dealing with that that’s where urgent care outreach, some of physician imitative and markeing strategies, we think are going to help in that particular funds, but it is quite competitive on the commercial side in many of our markets..

Thank you, Ralph..

And we will go next to Sheryl Skolnick at Mizuho Securities..

Thank you so much. So it was top comp and not an easy business ever, so good job. And thank you for the guidance and the explanation. I want to put it -- dig in a little bit more into your thought process so about the 2017 and then preparing perhaps for changes in the ACA.

So for 2017 you help me think about how if you are positioning the company vis-à-vis what we seem to see in the rest of the industry which is declining inpatient utilization coupled with what sounds like some changes in the dynamic with managed care in some of your markets, when do you start seeing that pressure reverse, is it a second half 2017, where do you start to get that the list of the investment you are making versus the competition and maybe gaining back some of that commercial market share, or are we likely to see some increasing pressure of managed care trying to outpatient at the hospital and balancing that out we kind of look the way we do it beginning of the year, because I think that volume assumption is really key to the guidance.

And then also what preparations then you are making this year to the potential for having more uninsured next year?.

So let me -- well first of all we don’t believe that inpatient utilization is declining we think ACA market is growing because of population trends, because the aging of the baby boomers the kind of clinical technologies, all those things that have been driving demand historically are going to drop demand in the future at least in the intermediate run we believe that clearly we had a five and six quarters cycle that was accelerated demand that we experienced tremendous volume growth that part of the comparison challenges that we had in the past year.

But we have seen a sort of normalized where we believe the markets are going to yield inpatient demand growth of roughly 2% across our market. As far as any managed care activities I don’t think that there is any unique managed care utilization management initiatives or care model initiatives that are impacting the market in any significant way.

Possibly on the fringes [ph] here they are not anything at its core and how it's impacting overall demand, nor we see that in the short run to intermediate run either. So those two dynamics aren’t really evident across ACA's market. With respect to our capital and some of our initiatives that amount of money is travelling in throughout the year.

It feathers in in 2016, a lot of our projects come in online at different points of 2017, 2018, and so forth. So is difficult to say that there's a bolus that's going to hit in the last half of the year for the first half of the year that's going to change our volume prospects.

It tends to feather itself into our overall capacity and opportunities over sort of a consistent kind of timeline where just happening from month to month to month. And so we're not anticipating anything unique. As far as changing our model and approach to the prospects for growing uninsured, this past year our uninsured activity was flat to down.

I think Bill, in total....

4% growth. We were down in the fourth quarter..

Yeah in the fourth quarter. And we've gone through cycles where payer mix have shifted a bit, clearly for us it’s the variable cost that we would incur in taking care of those patient's.

As the incremental impact obviously be -- if the Affordable Care Act strips away a 100% of the insurance like Milton was saying, that's a different dynamic for us, but I don't think it significantly changes our core strategy maybe some things on the fringes around how we pace initiatives or how we do certain decision making around that.

But we still have opportunities we believe on the core operations of HCA and that they can continue to yield value for the company..

All right, thanks, Sheryl..

And moving next to Gary Lieberman at Wells Fargo.

Sir?.

Good morning, thanks. You did a good job of controlling labor expense in the quarter.

Can you talk about the more broad pressures you're seeing on labor supply and how much of that is a risk to your numbers in 2017 and then maybe just comment on the robust, taller growth that you saw this year?.

Okay, this is Sam again. On labor expenses I’m really pleased with how the company was able to manage it for labor expenses this year. We saw the modest productivity improvement which I think is somewhat of a reflection of the operating leverage that we have from the volume growth. We were able to moderate our contract labor growth for the year.

It was only up 6% for the quarter, it was up 4% nursing continues to be a challenge for the company but we are making progress with a number of our initiatives around on boarding nursing, around training nurses, around recruitment in those areas and we still continue to manage that particular component of our expense structure effectively.

The trends going forward are modestly under pressure compared to this past year we are expecting wages to be up a little bit, maybe 50 basis points over where they were but that’s embedded in the guidance that Bill gave.

From the supply and other expense standpoint no significant inflationary pressures that we see at this particular point in those categories that will create any unusual risk in our expense structure for 2016. So we feel pretty good about where the company is.

From that standpoint we have a host of initiatives underneath our expense structure that are driving toward efficiencies and we continue to evolve those, they center around better labor management approaches with one HR platform, our performance improvement change which we’ve talked about in the past continue to find opportunity to enhance processes in our facilities and efficiencies and in our clinical agenda it’s continuing to identify opportunities to improve supply cost utilization, blood utilization, better patient length of stay and those kind of thing.

So the combination of those are still a positive opportunity for HCA and one in which we believe we can execute on and mitigate some of these pressures. Thank you Gary..

And our next question is from John Ransom at Raymond James..

Hi, my question has been answered. Thanks..

Great. Thank you..

John, thank you..

[Operator Instructions] And we’ll move next to Michael Newshel at Evercore ISI..

Thanks, good morning.

With the caveat as you said earlier is getting harder to estimate, but could you just confirm what you think ACA contributed to EBITDA in 2016 and whether that's in line with what you're expecting?.

Yes it did in discover [ph] it in line with our expectations. We said this is contributing 5% to 6% of adjusted EBITDA and that’s a double [Indiscernible] 2016..

Okay. Thanks..

Thank you, Michael..

And we’ll go next to Scott Fidel at Credit Suisse..

Thanks, if you can give us an update on the Florida Medicaid outpatient rate cuts and what you are assuming in guidance and I know that you and some of your peers have been protesting those so just interested if there’s an update on that process there..

No there are several offers to try to adjust that, but it does not have a material impact on HCA or inside our guidance for 2017..

All right..

Thank you, Scott..

And we’ll go next to Gary Taylor at JPMorgan..

Hi good morning. I have a kind of a two part on CapEx just because it's such a big part of the strategy. It's more than doubled since the IPO. It's running almost 7% of revenues in the 2017 guidance, which I think is around the highest in the decade.

So the two part question is, is there a point where you see absolute CapEx dollars coming down? Are we kind of rolling on a kind of a bolus CapEx cycle and that could slow? And just the reason I ask is, I know you're trying to point investors towards earnings, but in 2016 there were $2.7 billion in CapEx and only $1.9 billion of depreciation so there's certainly some EPS benefit that isn’t reflected in free cash flow program and just wondering when those two numbers might narrow?.

Gary, let me take a shot at it but this is Sam and then Bill also may also have some comments on it. So our capital spending is really a direct reflection of the opportunities we see in the marketplace and demand that we see.

Sam was talking about in certain markets if we don't invest and expand to add more capacity than our growth will be limited by lack of capacity. So we're trying to stay up to speed of that or ahead of that. And so we have been increasing our capital spend upto record levels.

Quite frankly at the same time, as Bill mentioned in his comments we have been reporting and seeing a record levels of return on invested capitals as we’ve been spinning more capitals. So I think those investments have turned out to be very solid and good investments and value creating opportunities for our shareholders.

Now if the marketplace changes, we certainly have the ability to ratchet down capital spending. And so we've been through different cycles before.

When we went through the recession back in 2009, it takes a little while to ratchet down, because the project is in process, but we didn’t have the ability, and we demonstrated the ability to slow it down based on market needs, and the like. So and so I don't see today as being any different.

So right now, we're seeing demand in our markets and we're investing too meet the requirements of that demand and again, I've been quite pleased with the return overall on the investments that we've been making..

Gary, I think we got time for maybe one more question..

We will go next to Paula Torch at Avondale Partners..

Hey thanks for fitting me in. I was just curious about on patient access and maybe going back to the growth in the ER beds.

Wondering where that's coming from in particular, is it mostly growth in the freestanding ED space or is it hospital ER beds? And just given the competition that's increasing in the freestanding ED space, are you spreading that growth to other markets that you have where this just less competition? Or are you still seeing growth in some of your more concentrated areas?.

Let me give you some facility numbers. First Paula, this is Sam again. On the urgent care side, we operate 72 urgent care centers today. And we believe to be somewhere around 120 urgent care centers by the end of the year. The freestanding emergency rooms we operate roughly 62, I think today.

One of them just got converted to a hospital yesterday actually, it opened in Orlando, Florida so we're down to 61 I think as a result of that conversion. But we should be somewhere around 80 freestanding emergency rooms in operation by the first part of 2018.

But when you look at the bed top of emergency rooms beds growth, it's a blend of between probably 50-50, thereabouts. I don't have the exact number of the top of my head but it's pretty close to that, between hospital ER bed expansion as well as freestanding emergency room expansion.

I do think some of the market dynamics for freestanding emergency rooms has slowed a bit. We're not anticipating the growth in competitor units in 2017 that we've seen in the past 24 months. And so we see opportunities for HCA to deploy these facilities strategically across various markets to put our network in the best position they can possibly be.

All right, Paula, is that helpful?.

Thank you. That was helpful..

You are very welcome. I want to thank everyone for being on today’s call. We look forward to talking to you and seeing you soon..

And ladies and gentlemen, once again that does conclude today’s conference. And again I’d like to thank everyone for joining us today..