Quest Diagnostics Inc (DGX) Q3 2026 Earnings Call Transcript

Welcome to the Quest Diagnostics third quarter 2026 conference call. At the request of the company this call is being recorded. The entire contents of the call including the presentation and question and answer session that will follow are the copyrighted property of Quest Diagnostics with all rights reserved. Any redistribution retransmission or rebroadcast of this call in any form without written content of Quest Diagnostics is strictly prohibited. I would like to introduce Dominique Chokshi, Vice President of Investor Relations for Press Diagnostics. Please go ahead.

Thank you and good morning. I'm joined by Jim Davis, our Chairman, Chief Executive Officer and President, and Sam Samad, our Chief Financial Officer. During this call, we may make forward-looking statements and we'll discuss non-GAAP measures. We provide a reconciliation of non-GAAP measures to comparable GAAP measures in the tables for earnings press release actual results may differ materially from those projected risks and uncertainties that may affect crest diagnostics future results include but are not limited to those described in our most recent annual report on form 10k and subsequently filed quarterly reports on form 10q and current reports on form 8k for this call reference to reported eps refer to reported diluted eps and references to adjusted eps refer to adjusted diluted eps growth rates associated with our long-term outlook projections, including consolidated revenue growth, revenue growth from acquisitions, organic revenue growth, and adjusted earnings growth are compound annual growth rates. Now here's Jim.

Thanks, Dominique, and welcome everyone to this morning's call. I'm excited to discuss our strong performance in the third quarter and how our strategy to connect people and providers to innovative testing and actionable insights is illuminating paths for better health and generating shareholder value. We grew revenues 10% and adjusted earnings per share over 15% in the quarter on continued strength across our physician, hospital, and consumer channels complemented by productivity gains from automation and AI. Our robust organic revenue growth demonstrates that our solutions are fulfilling the expanding clinical care needs of an aging population, as well as the increasing number of people focused on prevention and wellness. With these growth trends and our strong performance, we are again raising our guidance for revenues and earnings per share for the full year. Now I'll provide more detail on how we executed our strategy across our key customer channels and operations during the quarter. Quest operates at the center of healthcare. We deliver solutions that make testing simpler and smarter for our core clinical customers, physicians and hospitals, as well as for customers in the higher growth areas of consumer health, life sciences, and data analytics. In the Physician Channel, we delivered high single-digit revenue growth in the third quarter on strong commercial execution and broad demand across our test portfolio. We also continue to grow in geographies where we've expanded our access in recent years through health plan collaborations and outreach acquisitions. We are excited about our collaborations with Fresenius Medical Care and opportunities to serve new customers based on our growing kidney diagnostics expertise. In addition, we are taking steps to serve the growing nephrology call point and were recently named the primary national lab provider for pre-dialysis chronic kidney disease testing for a kidney care organization. In the hospital channel, we grew revenues by double digits during the quarter on strong volume from CoLab Solutions with Corwell Health in Michigan. Reference testing revenues grew in the mid-single digits. As a preferred strategic partner, Quest provides a range of solutions to help hospitals address continuing financial, workforce, and other pressures. From reference and co-lab arrangements to outreach acquisitions, we improve quality, innovation, and efficiency. Our role, serving half of the nation's hospitals each year, continues to fuel a robust pipeline of potential co-lab collaborations and outreach acquisitions. During the quarter, we finalized a definitive agreement to acquire select outreach assets from a longtime CoLab customer, a leading health system in the Northeastern U.S. We expect to close this transaction later this year. In the consumer health channel, we continue to generate robust growth as we delivered solutions that enable people to own their health. We are excited to announce the ability for iPhone and iPad users to order labs directly from the Apple Health app, which we see as a continuation of our strategy to deliver innovative solutions that will fulfill the growing interest in preventative health and wellness. Users of the Apple Health app will be able to seamlessly purchase, schedule, and receive test results for over 50 biomarkers, including APOB and LP little a, all within the app. The panel also includes biometric measurements such as blood pressure and weight at the same time blood is drawn at one of our 2,000 patient service centers. The offering will unlock greater health insights based on both biomarker and biometric data, and we look forward to the full launch of this service later this year. At Quest, we often say that wellness is not the absence of sickness. It's health that is proactive, personal, and connected. Through questhealth.com and our many collaborations, we are making wellness possible for more people. We expect our growth rate across consumer health to exceed 30% for the full year. Turning now to advanced diagnostics, we continue to focus on delivering innovative tests in five key clinical areas, advanced cardiometabolic and endocrine, autoimmune, brain health, oncology, and women's and reproductive health. During the quarter, we grew revenues by double digits for key tests across several of these key areas, including in advanced cardiometabolic, hormone, and Alzheimer's disease. As we approach Alzheimer's Disease Awareness Month in November, I'd like to share our view of this fast-changing area of dementia care. Many diseases today are highly preventable thanks largely to diagnostic innovations enabling early diagnosis. We envision a future where Alzheimer's is also a preventable disease and primary care physicians guided by blood-based tests diagnose and even treat the disease at a much earlier stage. We also believe our multi-biomarker approach can improve clinical evaluation of Alzheimer's disease and other dementias. Over the summer, we announced that we will soon add the FDA-cleared Roche P-Tau-217 test to our portfolio. We launched a new AD-Detect panel with APOE, amyloid beta, and P-tau-217 as these biomarkers provide different but complementary information to improve accuracy. For instance, P-tau-217 can falsely elevate with some comorbidities, so a physician may need to refer to amyloid beta to confirm a true positive for Alzheimer's. Blood testing for this highly complex disease is in the early phases of development and we look forward to adding significant new biomarkers to our portfolio to support earlier diagnosis and treatment. In Women's Health, we recently formed the first industry collaboration with Waters Corporation focused on providing access to OnClarity's self-collection kit through clinical, health plan, and consumer health channels, including patient service centers in the United States. This new collaboration builds on our experience providing HPV self-collection options for cervical cancer screening with a new, convenient at-home option. We expect to introduce the Waters Innovation to clinicians, health plans, and consumers of QuestHealth.com next year. I'd like to now turn to operational excellence. We remain on track to deliver 3% in annual cost savings and productivity improvements through our Invigorate program. Automation and AI continue to be major drivers of improvements in quality, productivity, and efficiencies. As one example, specimen aliquoting involves splitting specimens into small portions prior to testing. The process traditionally requires several human touch points, raising the risk of errors that can slow down the whole testing process. During the quarter, we extended an automated aliquoting solution to three drug monitoring labs to enhance quality and efficiency. Today, 10 of our labs use an automated aliquoting solution, and we plan to extend these capabilities to other labs. We also recently began to use AI I at our Clifton, New Jersey lab to scan water for signs of microbes and other impurities as part of our dialysis water testing services. The solution improves quality as well as efficiency because it automatically releases specimens with negative findings so our medical team has more time to concentrate on positive or questionable cases. Lastly, Project NOVA, our initiative to enhance the experiences of healthcare providers and patients, recently advanced from the design phase to the solutions build phase, and we are on schedule to begin to deploy Epic Solutions in our first lab in the fall of 2027. Our strong third quarter reflects the critical role lab insights play in our nation's healthcare. Before I turn it over to Sam for details of our performance and guidance, I want to share our perspective on the 2027 preliminary rate setting process under PAMA and steps we are taking to support passage of the Results Act. Since PAMA was passed into law in 2014, we have been concerned about the flaws in the data collection process. After six years of PAMA delays by Congress, labs were required for a second time to provide their lab data in 2026. We remain deeply concerned that the data collection process this year was also flawed and the resulting preliminary rate cuts for 2027 are excessive. With ACLA, we continue to advocate for the passage of the bipartisan Bicameral Results Act to permanently reform PAMA to ensure the data used to set rates properly reflects the market. Over 135 co-sponsors in Congress share our concerns about PAMA and our commitment to results. We have been told by our Champions on the Hill to expect CBO to score the legislation by mid-November. Securing a score is an important milestone as the sponsors work toward potentially including the Results Act in any year-end package. Results is the innovative reform our industry and patients need and we are calling on Congress to enact this important legislation by year's end. Now I'll turn it over to Sam for more details on our performance and guidance before sharing some final thoughts about the quarter. Sam?

Thanks, Jim. As Jim shared, we delivered a strong third quarter with consolidated revenues of $3.1 billion, up 10% versus the prior year. Revenues for diagnostic information services were up 10.2% compared to the prior year and 10.1% organically, reflecting continued strong growth in our physician, hospital, and consumer channels. Total volume measured by the number of requisitions increased 14.5 percent versus the third quarter of 2025, with organic volume up 14.4 percent. Our Corwell Health and Fresenius Medical Care relationships contributed 9.5 percent of volume in the quarter. Excluding these two relationships, volumes grew by 5 percent. As anticipated, total revenue per requisition was down 4.2% versus the prior year due to the Corwell and Fresenius business mix. Adjusting for that business mix, revenue per requisition was up by 1.7% versus prior year, driven primarily by an increased number of tests per requisition. Unit price reimbursement remained generally flat, consistent with our expectations. Reported operating income in the third quarter was $479 million, or 15.5% of revenues, compared to $386 million, or 13.7% of revenues last year. On an adjusted basis, operating income was $517 million, or 16.7% of revenues, compared to $458 million, or 16.3% of revenues last year. The 40 basis point improvement versus prior year was driven by organic revenue growth, partially offset by wage increases and the business mix impact from Corwell and Fresenius. Reported EPS in the quarter was $2.78 compared to $2.16 cents a year ago. Adjusted EPS was $3 versus $2.60 in the prior year, an increase of 15.4%. This increase was largely driven by strong organic operating performance. Cash from operations was $1.49 billion year-to-date versus $1.42 billion in the prior year. This year-over-year increase is the result of higher operating income in the current year, partially offset by timing of net working capital and prior year favorability associated with a one-time CARES Act tax credit. Turning now to our updated full-year 2026 guidance, with our strong performance and continued momentum across our business, we are raising and narrowing our full-year revenue and EPS estimates. benefits. We now expect revenues to be between $12.065 billion and $12.105 billion, reflecting a growth rate of 9.3% to 9.7%. Reported EPS to be in a range of $10.21 to $10.31 and adjusted EPS in a range of $11.25 to $11.35. Cash from operations to be approximately $1.9 billion and capital expenditures to be approximately $550 million. Our 2026 full year guidance reflects the following considerations. The Revenue Guide does not include any contribution from prospective M&A other than what we have announced to date. NOVA expense expectations remain consistent for the full year at an EPS impact of $0.25, with approximately 70% of these expenses to be incurred in the second half of this year. Operating margin is expected to expand versus prior year. Share count is expected to be slightly below 2025. Adjusted effective tax rate is expected to be consistent with 2025, and interest expense is now expected to be lower than 2025. Looking ahead, while we will provide 2027 and longer-term guidance at a later time, I want to offer a few comments on the potential impact of PAMA. The PAMA impact for 2027 is estimated at approximately 1% of total company revenues, consistent with our previous commentary. The cumulative impact is expected to be less than 1.3% of total revenues for years 2027 through 2029. We intend to offset some of this anticipated headwind. Consistent with prior years, we will provide 2027 guidance in the context of our fourth quarter and full-year earnings results early next year. We also look forward to sharing our long-term outlook, along with updates on our growth strategies, at our 2027 Investor Day on March 25th at the New York Stock Exchange. We will provide additional information on this event over the coming weeks. With that, I will now turn it back to Jim.

Thanks, Sam. In summary, during the quarter, we delivered robust revenue and earnings growth on sustained demand from physicians, hospitals, and consumers, complemented by productivity gains from AI and automation. Revenues grew by 10 percent, and adjusted EPS grew by over 15 percent, demonstrating continued broad demand for our innovations and insights. With our strong business performance and growth momentum, we are raising our revenue and EPS guidance for the full year. I want to close by thanking my Quest colleagues for their commitment and care to delivering diagnostic insights to create a healthier world, one life at a time.

Thank you, Jim. Now we'd be happy to take your questions. Operator?

Thank you. We will now open up to questions. At the request of the company, we ask that you please limit yourself to one question. If you have additional questions, we ask that you please fall back in the queue. To be placed in the queue, please press star 1 from your phone. To withdraw, press star 2. Again, to ask a question, please press star 1. Our first question comes from Anne Hines with Missoula Securities. You may ask your question.

Anne Hines- Good morning and thank you for the question. Thanks for the details on PAMA. Can you just provide some maybe color on how much of the PAMA headwind you could offset and maybe some other high-level headwinds and tailwinds we should consider for 2027? Thank you.

Thanks, Andy. Good morning. Let me just make a few comments on PAMA, the data collection process, and then I'll have Sam talk about offsets and things like that. So CMS yesterday released some very important data. I don't know if you all saw that. We had been pushing CMS since they announced the fee cuts to provide the information and the volumes by the segment. So how much of the data came from independents, how much came from hospital outreach, and how much came from POLs. Recall in the last survey that over 90% of the data came from independent labs. And independent labs surely do not have 90% share of this market. On the new, what they released yesterday is that the independence represented 76.5% of the volume reported. Again, it is way overestimating the share that independent labs have. Hospital outreach, which has a significant amount of share, hospitals owning outreach share, was less than 10 percent of the data reported. So if you don't have information, strong volumes being reported by the hospital segment, again, it's going to shift the volume-weighted median way to the left. So with this information, it emboldens us even further to push fast and furious for the Results Act. Now, what we're doing, our trade association, Quest, and all the members are continuing to work hard to pass the Results Act. We are eagerly anticipating a score by the CBO. We think that will come at some point in mid to late November. And once that score comes out, the primary committees, House Ways and Means, House Energy and Commerce, Senate Finance, they'll convene, and we're going to urge these committees to include the Results Act in some end-of-year package. So we're going to continue to push hard for the Results Act. Again, we're emboldened even more because now we realize that, again, the data collection process has way overestimated the share position of the independent labs. So, Sam, let me give it to you to talk a little bit about our budgeting process and offsets and things like that.

Yeah, I think – thank you, Anne, for the question. I think you asked about PAMA offsets. First of all, as we mentioned on the call, the impact from PAMA we expect to be next year, roughly 1% of revenues. That's largely consistent with our expectations prior to the data collection and the outcome of the data collection. As we have indicated repeatedly, I think, in the past, we intend to offset a portion of this impact. When we announce our Q4 results, provide guidance, we will give you a lot more clarity on what that means, assuming that the PAMA impact is real and has materialized or is about to materialize because PAMA has essentially the prices have come down, if that, in fact, were to happen. In terms of just qualitatively on 2027 impact, I mean, first of all, as I said, roughly 1% of impact from PAMA. We intend to offset a portion of it. We're going to look at many aspects of our, I would say, infrastructure, support functions, and look at potential efficiencies that we can generate beyond the efficiencies that we have been generating across our business. We will not impact things that drive growth. We will not impact our front line. We will not impact our lab operations in any way or our ability to serve patients because utilization has been very strong. And we continue to be very pleased with the utilization that we're seeing. So, again, in terms of 2027, without giving you numbers, I would say the CORWA and Fresenius impact, which we expect this year to be roughly 3% in terms of additional revenue growth, that obviously will not be a factor next year in terms of growth because we will lap these partnerships in October of this year. We've got the 1% impact from PAMA that, you know, if it were to happen, that would be a negative impact on revenue growth. Utilization, we expect it to continue at the same levels that we're seeing. There's no reason to expect any moderation of the utilization that we're seeing. From a margin perspective, Anne, we do expect to see some continued improvement on the margin from those two partnerships, Corwell and Fresenius, as we enter 2027. As we said before, you know, those came with lower margins because of integration and investments, integration expenses and investments. But we expect improvement on those margins in 2027. We will be making additional investments in NOVA as expected because we intend to launch, at least launch EPIC in our first lab at the end of 2027. So we do intend to make some investments in NOVA that are beyond the investments that we've made in 2026. So there will be some additional expenses year-over-year regarding NOVA. And from a pricing perspective, ex-PAMA, we expect to maintain this flattish outlook in terms of pricing across our third-party payer partners.

Great. Thank you. Next question, please.

Thank you. Our next question comes from Michael Cherney with Leering Partners. You may ask your question.

Good morning, and thank you for taking the question. And maybe if I can just dive in a little bit on that underlying 5% volume growth. This seemingly tracks above most market stats that we see. And so as you think about where that growth is coming from, can you give a little bit of the dynamics of where your execution comes from versus market underlying performance? And how do we think about your growth going forward in terms of what you have the ability to control relative to trying to outpace the market. Thank you.

Yeah. Good morning, and thanks, Michael. So, let me start, and Sam can interject here. So, the 5% you referenced here is our volume growth in the quarter, X Fresenius and X Corwell. So, it was 5% revenue growth, 6.6%, 5% volume growth and 6.6 percent revenue growth. Now, as we look across the channels that we always talk about, our physician channel, our hospital channel, both reference and co-lab, and our consumer channel, we are seeing strong growth across all three. In the physician channel, in the quarter, revenue grew above mid-single digits, so strong revenue growth, strong volume growth. In our hospital reference business. Again, this is reference, not CoLab, not Corwell. Our volumes were double digit in the quarter, revenue slightly less than that, but strong growth through our hospital segment. And as I noted in the commentary, our consumer channel all in, both Quest Health Direct plus our partnerships continue to generate growth north of 30% this year.

So I would tell you it's across all channels in our business and we feel good about this going into next year great thank you operator next question please thank you and this question comes from Erin Wright with Morgan Stanley you may ask your question great thanks so I want to dig into consumer a little bit and talk about your partnership with Apple how do you expect that to ramp here as it kicks off and are there any nuances to the relationship that are inherently different from contracts with other wearables or consumer platforms, and how material kind of do you think this will be for you? And can you remind us of just the overall pricing environment across the consumer-directed business? Thanks.

Yeah, thanks, Erin. Look, we're really excited about the Apple Health partnership. It is in what I would call data testing mode at this point and we expect to go live. They expect to go live at some point later this year before the start of next year. I gave a lot of detail in the script. It's a $119 rack, the types of biomarkers. We're going to do like we do for other what we call employer health stuff. we do check the patient's weight and blood pressure in our PSCs. That is routine for other types of wellness work that we do. And it's a seamless experience that one can use through the Apple Health app. I can't really provide a forecast because we'll have to wait and see after the launch how quick the update is, but it's a great partnership. Look, the ability to combine biometrics with biomarkers, we strongly believe will unlock additional insights into what is going on inside the human body. Those insights then can lead to actionable, you know, actions for the patient consumer to take in order to prove their biomarkers, which ultimately leads to an improvement in their human health. So excited about it. Again, expect full launch later in the year, and we'll know more in terms of, you know, the uptake, and we'll probably comment on that in January.

Yeah, you asked Aaron as well, this is Sam, about pricing across consumers. So let me focus more on margins across consumer. Margins across our consumer business are actually accretive to our overall operating margins so that's an important note because as you know as you see this this channel is growing above 30 percent and it's really driving also accretive margins the reason margins are accretive to our overall business number one no denials no patient concessions so we benefit from that tailwind in addition to the fact that these are much more dense recs so we see sometimes 10 tests per rec and maybe even north of that in certain cases so you see dense tests dense recs that help our overall tests per rec and also more accretive

margins so that's that's the part that i wanted to make sure is clear all right great thank you next question operator thank you and this question comes from teichel peterson with jeffrey you may ask your question.

Hey, thanks. Want to maybe just pick up on the margin commentary. So, you know, 40 bips this quarter, how much of that volume leverage versus invigorate? And maybe can you just talk a little bit about how you're thinking about the automation AI angle on margins going forward?

Yeah, I think, Tyco, to be fair, it's a combination of the leverage you get off of volume. You know, this is a rather high fixed cost business. So, an incremental So REC drops down at a very, very nice contribution margin. But our Invigorate program, you know, we've always targeted for our Invigorate to offset wage inflation at 3 percent, probably north of 3 percent this year, somewhere between 3 and 4 percent. That's at least $120 million of pressure on us every single year. I don't know that we mentioned fuel cost in the script, but we had given an estimate of $10 million for the year. It's actually going to be closer to $14 million based on prices going up again here in the third quarter, and we don't see them coming down at this point in the fourth quarter. So we're offsetting that. So our Invigorate program continues to deliver. you know, you push through the organic volume, you deliver on the invigorate, and that's what leads us to, you know, 40 basis points of margin improvement in the quarter.

Thanks, Jim. Next question, operator.

Thank you. Our next question comes from Lou Li with B of A Global Research. You may ask your question.

Great. Thank you for taking my questions. I think earlier you mentioned the utilization is still pretty good, but I'm I'm wondering, can you comment a little bit on the ACA disenvolvement impact, like what do you see in the second half? And then maybe just tag on a one short one. I think you have an AK out this morning on the cybersecurity. Wondering if you have like any more color on the potential financial impact.

All right. So, let me address the ACA and Sam will give some comments on the additional AK. Okay, so in the quarter, we saw a reduction of about 11% in terms of rec volume from ACA exchange members. So requisition volume down 8%, but our test per rec on those requisitions was up 8%. So the net impact from a pure test standpoint was down 3%. When we then look at the types of tests that are being ordered on that right requisition it suggests a higher acuity patient so these are higher revenue tasks so the net impact overall was maybe 10 basis points of revenue loss um on the exchange so um it's it's you know next to nothing so um we're not really feeling an impact from it like some of the health systems hospitals are reporting um in terms of the additional 8K filing. Sam, you can comment on it.

Yeah, thank you for the question. So yesterday we learned of unauthorized access to a test ordering system used by certain clients who don't use an EMR. As we stated in the 8K that we filed this morning, this incident has not materially disrupted our business operations or our ability to serve physicians and patients. So the investigation is it's in its early stages. We're not in a position right now to provide any more information or take additional questions on the details at this time, but we will provide updates as appropriate as we go forward. Thanks, Sam.

Great.

Next question, please.

Thank you. The next question comes from Lisa Gill with JPMorgan. You may ask her question.

Thanks very much. Jim, I just want to go back to your comments around PAMA and just really understand two things. One, when we think about the Results Act, have you quantified what the impact of results would be. Two, you know, we've heard rumblings that potentially we have another delay of PAMA as they try to work through results, so what's your anticipation there? And then lastly, I know it's been asked around the offsets, but, you know, historically you've talked about this being roughly $100 million, and now you're talking about 1%, which would be like $125 million. So as we think about modeling for 27, all things being equal today, should we assume that there's roughly, you know, 20 or 25 million that you can offset? Or is it more logical at this point to put 125 million into the model?

Okay. So, again, on the data itself, 76.5% of the data collected by CMS here in 2026, which was from the January to July period of 2025, came from independent labs, which we know is significantly higher than the share that independent labs have. Only 9%, less than 10% came from hospitals, and we know that the share of the outreach market by hospitals, primarily from the physicians they own, is significantly higher than 9%. That obviously affects the volume-weighted median calculation, and in a very adverse way. So, again, with respect to the Results Act, it requires a CBO score. We expect that CBO score to come, we're being told, in the mid to late November time frame. And then we go hard at work through the committees. Now, I can't give you a probability of of Results Act getting included, or the potential for another delay. What has seemed to become traditional at the end of the year is some type of healthcare package. There's always extenders that look to be extended, and so our goal is to be included in that end-of-year package. Now could there be a delay in the rates? Hey, that's always a possibility. And, obviously, if we can't, if we don't see results getting done, if the committees can't get together and get agreement on the new approach, then we'll push for a delay. Having said that, the House Ways and Means, I'm sorry, House Energy and Commerce had a hearing on the Results Act earlier, late this summer. We believe it was a positive hearing, so we believe it has momentum. We've stated that over 135 congressional people have signed on to support it. And so when Congress is back in session post the election, we're going to be hard at work. We're hard at work right now. We're visiting with staff members of both the Senate and the finance side that still remain in Washington, D.C. Now, in terms of the offset, look, we'd love to give you a number, and we're not being coy at all. You know, we said one percent of 20, you know, 2026 revenue, $12 million, can't give you guidance yet, but expect, you know, expect it to be another $500, $600 million next year. So take one percent of that number, and that is the impact. Now, that's from Medicare. That's from Medicaid plans that are absolutely tied to the Medicare. It's not managed Medicaid. It's straight Medicaid plans. And then there's a very, very small number of health plans that over the last five years, we didn't get off of a tie to that schedule. But over the last five years, the vast majority of our health plans, we've taken out any language that would tie their fee schedule to a Medicare fee schedule. So we roughly feel it's in that 1% range. Now, is 100% of that going to drop to the bottom line? Absolutely not, okay? We're in the midst of our budgeting process. As Sam said, the things we're not going to touch are, you know, the variable cost structure of the company, which we produce Invigorate Savings on every year. We can't touch lobotomy. We can't touch logistics. We're not going to touch the – there's always going to be more efficiencies in the lab. But given the incredibly strong volume growth that we have right now, we have to keep the frontline physician staffed in order to handle the volume. The best way to offset this is to grow our way out of it. Now, we're left with a billion dollars of other costs in the company outside of the work required to provide patient results. And as Sam indicated, we're in the middle of our budgeting process right now. We go through every program in the company. and, you know, some will delay, some we're going to keep because they're important to growth in 27, 28, and 29. So there will be some portion that we offset. Again, we're not trying to be coy. We're working through our budgeting process, and we will give you, you know, the firm update on our January earnings.

Yeah, so key takeaway, Lisa, is don't assume the full impact in your model. There will be an offset.

We can't tell you what the offset is because we're working through our our plans right now okay thank you next question operator thank you and this question comes from luke serga with barclays let me ask your question great thanks and uh jim congrats on your on the brew crew um i just wanted to follow up on the uh the pama stuff because um you just said at a recent sell site conference that you didn't think it was going to be more than a hundred million dollar impact and then now you're talking about 125 to 165 after you kind of sharpen your pencils on it. Can you just talk about where that incremental headwind came from or, you know, what led you to, you know, for the increase there?

Yeah. Look, I think we've always said a range of $100 to $120 million, not knowing the results of the latest data collection process, which, again, we believe to be flawed. There were 1,500 codes that are going to get some type of reduction. And 775 of those, Luke, are going to face the maximum 15% cut. So it wasn't an exact science that we knew until the data came out. But there's, again, 775 that get a 15% cut. 1,200 in total will get cut of the 1,550. And so there's less than 15% codes on another you know roughly four to five hundred so that's how we sharpen the pencils now did we expect it to be 15% on seven seven hundred and seventy-five no we didn't we didn't expect the data process to come out this way and obviously based on the data I gave you that seventy six and a half percent of the data came from independent labs we thought it would be a better process but it wasn't and we can't change that now all we can do is push for the results I will give you one prediction, though, today, and that is the Brewers in six games. So thanks for the question.

Thanks, Jim. Next question, operator.

Thank you. And this question comes from David Westenberg with Piper Sandler. You may ask your question.

Hi, guys. This is Scott for Dave. Thanks for taking the question. Could you help us understand the drivers of the increase in DSO in the quarter? I think you previously described the movement as time-related, but can you just remind us how much of that is reflecting normal seasonality or collection timing and also how should we think about the cadence of DSO over the next 12 months? Thanks.

Yeah, so thank you for the question. I mean, DSOs, first of all, let's talk about a couple of things which drive DSOs that maybe are part of your question and maybe to alleviate some of your concerns there. we look at two key things that are drivers of our business and our ability to collect from our patients from our customers and those are you know bad debt and what we call patient price concessions bad debt is usually what we attribute to our inability to collect from certain client bill customers mostly hospitals and patient price concessions are the inability to collect from patients on whether it's their co-pay or if they're uninsured patients that we haven't collected from at the time they come to our PSC, for instance, then there might be a bill that they owe them that we might not be able to collect from them. Now, for those two, bad debt and patient price concessions, we have not seen any meaningful increase on both of these. Patient price concessions are flat versus same period last year, bad debt is mostly in line with what we have seen traditionally. So there's no issues with regards to those two. DSOs are up about three days since year-end. A lot of that is mixed, mixed driven by some of our client bill business, which usually has longer terms on it. That doesn't mean it's higher exposure. It just means we have longer terms and we collect on those longer terms accordingly. There's also a nuance here with regards to less collection days in Q3 and so far this year in terms of less banking days than we had last year. So that also drives DSOs higher.

In terms of what we expect, again, no meaningful impact because we are still seeing no meaningful negative impact on patient price concessions or bad debt those are still in line with what we saw what we see historically thanks Sam next question operator thank you our next question comes from Elizabeth Anderson of Evercore ISI you may ask your question hi guys thanks so much for the question maybe one housekeeping question or one longer question in terms of I heard what you said about the NOVA investment in terms of your expectations being stable, 3Q versus 4Q, sorry, for the full year. Is that true within the quarters as well? And then, two, if we think about PAMA, you've done a great job, obviously, being able to share with us what you know so far about the potential impact. Are you expecting it to have any impact on other types of pricing apart from those who just specifically price based on the CLFS?

Yeah, thank you, Elizabeth. So let me start with the NOVA piece, and Jim can talk about the PAMA. impact and I think you're referring to some of the health plan contracts with regards to NOVA so let me just make sure everybody is on the same page we we expect this year that it's going to be 25 cent impact we expect that 70% of that impact is going to be in the second half 30% of the first half our expectations between Q3 and Q4 is that there's a slight ramp in Q4 versus Q3 So if you think about that 70% in the second half, it's more tilted towards Q4 in terms of investment, which is fairly in line with the activity on the NOVA project overall. As we progress through this project, we are incurring more expenses around resources that are involved and all the efforts that go into it as we now go from design to build stage. Jim, did you want to refer to the PAMA or address it?

Yeah, so, again, on the payment, in fact, $120 million, which includes Medicare and straight Medicaid state fee schedules that are tied to Medicare. Look, we have probably over 700, maybe even closer to 1,000 contracts with various health plan organizations. I know we're used to the big five or six and all the blues plans, but there's a lot of various health plans out there. A very, very small minority of those contracts had some tie to the Medicare fee schedule. Over the last five years or since the first hit on PAMA, our organization worked incredibly hard to make sure in all of our contracts that language was completely taken out. And for the most part, it was. But I would call that additional, you know, we look at our health plan book of business. every year we're getting some price increases we've been saying on the calls that we've been flat to slightly up so whatever that impact is will be worked in the construct of the entire health plan set of contract negotiations as you know we we routinely negotiate a third at 25% you know a third to a fourth of all health plan contracts every year in our business and so any addition beyond that you know one percent impact is worked within the construct of those of those negotiations

great next question please thank you our next question comes from kevin caliendo with ubs you may ask your question thanks thanks for getting me and i appreciate it um i just want to talk a little bit about the organic volumes and and sort of what's driving and and how to think about the weather impact and hicks and and the like so organic volumes x percentius and corwell improved sequentially rev for rec came down sequentially and i'm just wondering if there was anything related to mix and how to think about weather year over year if there was any impact i think there was no weather last year no weather this year if this is like a true number and if there was anything in the mix that affected the REV-REC number, which, again, I think was closer to 3% in the first half of the year, 1.7% in the third quarter.

Yeah. Thanks, Kevin. Let me address it. So, organic volume growth in the quarter, again, 5%. In Q2, it was 4.1%. For the year, it's running 4.3%. You did note a shift in rep per rec increase from Q2 to Q3, and Q2 roughly 2.9%, in this quarter 1.7%. Here's what's driving it. As I mentioned on one of the questions, our growth from the hospital reference business was up significantly. It was double-digit volume growth in the quarter. What we saw in the quarter, what was driving a bunch of that growth was a lot of single test recs from some very large health systems that were leveraging our LP little a business or leveraging our Alzheimer's business. And so hospital reference work in general has a very low test per rec. It's like 1.6 test per rec. We saw that number drop slightly because, again, a lot of organizations started to leverage our capacity for some very important tests. The other thing we saw in the quarter, we haven't talked much about it, but was the cyclospora spurt that the volume that came our way during the third quarter. Those were a lot of single test requisitions. The revenue on that test is pretty low, 15, 16 bucks or somewhere in that range. And so that's why we saw a shift down in the growth rate of our REF per REC. Again, it's still growing. It's growing at a very nice clip. It just slowed from Q2 to Q3. But again, nice volume increase sequentially Q2 to Q3 from 4-1 to 5%.

So, Kevin, let me add a couple of points as well, I think, to address the other parts of your question. I mean, first of all, just to close out on the REF per REC comment from Jim, within that 1.7%, excluding Caldwell and Fresenius, within that growth of ref per rec, there is no negative price impact, okay? So, I just want to make sure that's clear. Price is relatively flat, which is in line with what we've been seeing in past quarters. With regards to volume, it is a clean volume quarter. The 5% has no unusual items within it. It doesn't have any weather or mostly no weather impact. We've had a pretty, I would say, good weather quarter here in Q3. So there is no negative weather impact. With regards to Hicks in the quarter, we did have a 10 basis point impact from Hicks. And Jim mentioned that earlier. Expectation for Q4 is that we've sized it as a 10 to 20 basis point impact from Hicks in Q4. But again, pretty modest impact because what we're seeing is higher acuity patients staying, tests for REC increasing with the patients that are remaining on the exchanges.

Thanks, Sam. Next question, operator.

Thank you. And this question comes from Jack Mann, who at the Operant Research. You may ask your question.

Thank you. Good morning. Hope you guys are doing well. I want to follow up on Tyco's margin question um but looking at it sequentially um i was just surprised i think 2q historically is usually the high watermark for the year and margins improved sequentially so i was wondering if uh maybe you could just walk us through was there anything that stood out for um why this year kind of bucked the normal seasonality and whether there's any change in the business that should be thinking about thanks yeah thanks jack and hope you're doing well this is sam so um you know from a sequential standpoint um yeah so we were uh essentially up and i'm referring to

operating margins here we were up uh 20 basis points versus q2 of 26 so the past quarter um you know a couple of things um as we think about that i mean we did have the improvement in the margins on Caldwell and Fresenius helping us as we go from Q2 to Q3. As we said, sequentially throughout the year, we're going to continue to improve the margin rate of those partnerships, so it's in line with that. Some SG&A leverage that we saw in Q3, some benefits on SG&A that we talked about in our prepared remarks, but really nothing that's substantial. But there's also a benefit related to supplemental deferred compensation, which is entirely driven by market performance. It's a mark-to-market valuation of those investments in our supplemental deferred compensation plans. We saw a hit from that in Q2. We saw really no material impact from that in Q3. And I'll remind everybody, that's a neutral EPS impact. It just impact operating margin but it did help q3 operating margins versus q2 so those are the the main things there jack nothing that uh you know that's materially impactful in terms of business performance except for the corwell and fresenius sequential improvement in margins that that we are pleased about great thank you operator next question please thank you our next question comes from Eugene Park with Baird.

You may ask your question.

Hi, thank you for taking my question. I wanted to get back into the PAMA estimates comments. You talked about 1.3 percent cumulative impact on revenue from 2027 through 2029. This implies, you know, some incremental impact in 2028 and 2029. Can you talk a bit more about year two and year three impacts? Thank you.

Yeah, thank you for the question. We're not going to provide a breakdown right now in terms of how that breaks down between 28 and 29. Again, these are estimates. We're still going through the data and really analyzing it and getting more precise on these estimates, especially for 28 and 29. But I think what we've said captures, you know, on a, I would say it captures mostly the impact that we expect in those two years, which is a 30 basis point cumulative impact of revenues and a roughly 1% impact of revenues in 2027.

Thanks, Sam. Next question, operator?

Thank you. Our next question comes from Jared Haas with William Blair. You may ask your question.

Hi. Good morning. Thanks for taking the questions and for sticking me in here at the end. Wanted to go back to the prepared remarks. You talked a little bit about the momentum you're seeing with kidney care and some of the momentum there even beyond Persenia. So just really interesting to hear that. I'm wondering if you could unpack how you think about the growth opportunity for that segment of the market going forward. And then when I think about your go-to-market, does it sort of require any incremental investment in terms of maybe specialized commercial resources to sort of best go after that opportunity? Thanks.

Yeah, thanks, and good question. I think, as everybody knows, we took on the laboratory testing associated with dialysis testing for end-stage renal disease patients that go through Fresenius health. And what it's done, and your question is really good, is it's opened up the door to a set of new relationships with a lot of nephrologists across the country, some of whom we were serving, but many of whom we were not serving. So, in fact, we have fielded a specialized sales force to call on nephrologists and offer a broad set of, you know, cardiometabolic testing associated with either early-stage kidney disease, mid-stage, or late-stage kidney disease. So that's why we were excited about the opportunity to begin with, and this just represents a whole new opportunity. It wasn't a segment of physicians that we routinely called on. If they were part of a specialty group, sure, we called on them, but it's getting a lot more focused by a specialized channel that we have in Quest Diagnostics, and it should result in additional opportunities as we go into 2027.

Thank you, Jim. And I think that was our last question. Jim, any closing remarks?

Yeah. First, again, thanks for joining our call today. We certainly appreciate all your questions and continued support, and we wish you a good day ahead. Thank you, everyone.

Thank you for participating in Quest Diagnostic's third quarter, 2026 conference call. A transcript of a prepared mark on this call will be posted later today on Quest Diagnostics website at www.questdiagnostics.com. A replay of the call may be accessed online at www.questdiagnostics.com forward slash investor or by phone at 866-388-5361 for domestic callers or 203-369-0416 for international callers. Telephone replays will be available from approximately 10.30 a.m. Eastern Time on October 22nd, 2026 until midnight Eastern Time, November 5th, 2026. Goodbye.