Earnings Call Transcript - DGX Q3 2021

Operator, Operator

Welcome to the Quest Diagnostics' Third Quarter 2021 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 the written consent of Quest Diagnostics is strictly prohibited. Now I'd like to introduce Shawn Bevec, Vice President of Investor Relations for Quest Diagnostics. Go ahead, please.

Shawn Bevec, Vice President of Investor Relations

Thank you, and good morning. I'm joined by Steve Rusckowski, our Chairman, CEO, and President; and Mark Guinan, 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 to our earnings press release. Actual results may differ materially from those projected. Risks and uncertainties, including the impact of the COVID-19 pandemic that may affect Quest Diagnostics' future results include, but are not limited to, those described in our most recent annual report on Form 10-K and subsequently filed quarterly reports on Form 10-Q, and current reports on Form 8-K. The company continues to believe that the impact of the COVID-19 pandemic on future operating results, cash flows and/or its financial condition will be primarily driven by the pandemic severity and duration, health care insurer, governments and clients payer reimbursement rates for COVID-19 molecular tests, the pandemic's impact on the U.S. health care system and the U.S. economy, and the timing, scope and effectiveness of federal, state and local governmental responses from the pandemic, including the impact of vaccination efforts, which are drivers beyond the company's knowledge and control. For this call, references to reported EPS refer to reported diluted EPS, and references to adjusted EPS refer to adjusted diluted EPS. Any references to base business, testing, revenues or volumes refer to the performance of our business, excluding COVID-19 testing. Growth rates associated with our long-term outlook projections, including total revenue growth, revenue growth from acquisitions, organic revenue growth and adjusted earnings growth, are compound annual growth rates. Finally, revenue growth rates from acquisitions will be measured against our base business. Now, here is Steve Rusckowski.

Steve Rusckowski, CEO

Thanks, Shawn, and thanks everyone for joining us today. Well, we had a strong third quarter as COVID-19 molecular volumes increased throughout the summer, while our base business continued to deliver solid volume growth versus the prior year and 2019. In late summer, we experienced some softness in the base business across the country, but saw a rebound in September. Importantly, our base business continues to improve sequentially in the third quarter, which speaks to the ongoing recovery. We have raised our outlook for the remainder of the year based on higher-than-anticipated COVID-19 volumes, as well as continued progress we expect to see in our base business, despite rising labor costs and inflationary pressures. The momentum of our base business positions us to deliver the 2022 outlook we shared at our March Investor Day. So, this morning, I'll discuss our performance for the third quarter of 2021, and update you on our base business. And then Mark will provide more detail on our financial results and talk about our updated outlook and underlying assumptions. But before turning to our results in the third quarter, I'd like to update you on the progress we've made in our quest for health equity initiative, a more than $100 million initiative aimed at reducing healthcare disparities in underserved neighborhoods. Since we've established it just over a year ago, we have launched 18 programs across the United States and Puerto Rico, ranging from supporting COVID-19 testing and vaccination events to educating young students on healthy nutritional choices to providing funding support for a long-haul COVID-19 clinic in Puerto Rico. Recently, we announced the collaboration with the American Heart Association that will expand research and mentorship opportunities for black and Hispanic scholars to drive hypertension management and COVID-19 relief. We're off to a good start, and I look forward to updating you on our continued progress as Quest for Health Equity enters its second year. Now, turning to our results for the third quarter, total revenue of $2.77 billion, down 40 basis points versus the prior year; earnings per share were $4.02 on a reported basis, down approximately 3% versus the prior year; and $3.96 on an adjusted basis, down 8% versus the prior year. The revenue and earnings declines in the third quarter reflect lower COVID-19 testing in 2021 versus the prior year, partially offset by continued recovery in our base business. Cash provided by operations increased by nearly 20% year-to-date through September, to approximately $1.75 billion. Now, starting with COVID-19 testing, our COVID-19 molecular volumes increased in the third quarter versus the second quarter, due to the spread of the Delta variant over the course of the summer. Testing began to increase meaningfully in mid-July and peaked in early mid-September. Our observed positivity rate peaked in mid-August, and has steadily been declining across much of the country in recent weeks. We performed an average of 83,000 COVID-19 molecular tests a day in the third quarter and maintained strong average turnaround times of approximately one day for most specimens throughout the surge. As clinical COVID-19 volumes declined, we are expanding our non-clinical COVID-19 testing to support the return to school, office, travel, and entertainment. We're making testing easy, fast, and affordable for school systems and other group settings across the country. We are currently performing K-12 school testing in approximately 20 states, with five additional states ready to come online. We're testing passengers on cruise lines, and Quest exclusively provided testing at the Boston Marathon earlier this month. In the base business, we continue to make progress on our two-point strategy to accelerate growth and drive operational excellence. Now, here are some highlights from the third quarter. Our M&A pipeline remained strong. In the third quarter, we completed a small tuck-in acquisition of an independent lab in Florida. We continue to build on our exceptional health plan access of approximately 90% of all commercially insured lives in the United States. At our Investor Day, we discussed how we have fundamentally changed our relationship with health plans, and we continue to see the promise of value-based relationships come to life. So, here's a couple examples. We are working with national health plans to help their self-insured employers improve quality, outcomes, and lower the cost of care for both the employers and their employees. Also, effective October 1, we gained access to one million managed Medicaid members in Florida, as their coverage transitions to Sunshine Health Plan. We're getting good feedback from the provider community and our growing testing volumes through this expanded access opportunity. Our hospital health system revenue continues to track well above 2019 levels, driven largely by the strength of our professional laboratory services contracts. As we highlighted previously, 2021 performance is benefiting from two of our largest POS contracts to date, Hackensack Meridian Health and Memorial Hermann. Altogether, our POS business is expected to exceed $500 million in annual revenue this year. Trends in our hospital reference business also remained steady, with third quarter base testing volumes above 2019 levels. We also generated consumer-initiated testing revenue through QuestDirect in the third quarter. While COVID testing has been a strong contributor to growth, we expect our base direct-to-consumer testing to more than double this year. Recently, we soft-launched a comprehensive health profile on QuestDirect, similar to our Blueprint for Wellness offering for employers. This expanded health panel offers a deep dive into consumers' health profile with a battery of tests and biometric measurements to provide a personalized health quotient score that can be used to track health progress over time. And then finally, our MyQuest app and patient portal now has almost 20 million users. In advanced diagnostics, we continue to ramp investments and see strong momentum in key growth drivers. We're seeing growth in non-invasive prenatal testing significantly above 2019 levels and saw solid contribution in our specialty genetics portfolio from Blueprint Genetics. We continue to work closely with the CDC to sequence positive COVID specimens in an ongoing effort to track emergent variants, expanding all of the work that we performed in the quarter. And then finally, we plan to introduce a test service based on a new FDA-approved companion diagnostic for a therapy from Eli Lilly for a certain type of high-risk early breast cancer. Quest will be the first laboratory to offer it to physicians nationally at the end of the month. Turning to our second strategy, driving operational excellence, we made progress and remain on track to deliver on our targeted 3% annual efficiencies across the business. Last week, we announced that we completed the integration and consolidation of our northeast regional operations into our new 250,000 square-foot next-generation lab in Clifton, New Jersey. This state-of-the-art, highly automated facility services more than 40 million people across seven states. In patient services, we are seeing all-time high numbers of patients making appointments to visit our Patient Service Centers. Now more than 50% of patient service center visits are now by appointment versus walk-ins. This enables patients to be very satisfied and also improves our ability to drive productivity for our phlebotomists. Similar to our immunoassay platform consolidation, we recently procured a highly automated neuro analysis platform that is expected to generate millions in annual savings once these new systems are standardized across our laboratory network. And then finally, I'd like to recognize and thank all of our nearly 50,000 employees who have worked tirelessly to provide critical COVID-19 testing to our country throughout the pandemic and continue to serve the healthcare needs of patients who depend on Quest every day. As a demonstration of our gratitude, we're assisting our employees with a one-time payment of up to $500 designed to reimburse costs they incurred during the pandemic. Additionally, another year of pandemic pressures and travel restrictions have made it very difficult for many employees to take their hard-earned time off. Therefore, we're providing a payout of most unused paid time off for our hourly employees to ensure they don't forfeit their earned unused time at year-end. Now I'd like to turn it over to Mark to provide more details on the third quarter financial performance and updated outlook for the remainder of 2021. Mark?

Mark Guinan, CFO

Thanks, Steve. In the third quarter, consolidated revenues were $2.77 billion, down 0.4% versus the prior year. Revenues for Diagnostic Information Services were essentially flat when compared to the prior year, which is reflected by lower revenue from COVID-19 testing services versus the third quarter of last year, largely offset by the strong ongoing recovery in our base testing revenue. Compared to 2019, our base DIS revenue grew approximately 6% in the third quarter, and it was up nearly 2%, excluding acquisitions. Volume measured by the number of requisitions increased 5.3% versus the prior year with acquisitions contributing approximately 2%. Compared to our third quarter 2019 baseline, total base testing volumes increased 9%. Excluding acquisitions, total base testing volumes grew approximately 4% and benefited from new PLS contracts that have ramped over the last year. We saw a rebound in our base business volumes in September, following a modest softening in August that we believe was at least partially caused by the rise of the delta variant and the timing of summer vacations. Importantly, our base business revenue and volume grew sequentially in the third quarter. This helps illustrate the ongoing recovery as historically total revenue and volume typically step down in Q3 versus Q2 due to summer seasonality. As most of you know, COVID-19 testing volumes grew in the third quarter versus Q2, which was in line with broader COVID-19 testing trends across the country. We resulted in approximately 7.6 million molecular tests and nearly 700,000 serology tests in the third quarter. So far in October, average COVID-19 molecular volumes have declined approximately 10% from where we exited Q3, but are still above the levels we expected prior to the surge of the delta variant, while the base business continues to improve since September. Revenue per requisition declined 5.4% versus the prior year driven primarily by lower COVID-19 molecular volume and to a lesser extent recent PLS wins. Unit price headwinds remained modest and in line with our expectations. Reported operating income in the third quarter was $652 million or 23.5% of revenues compared to $718 million or 25.8% of revenues last year. On an adjusted basis, operating income in Q3 was $694 million or 25% of revenues, compared to $831 million or 29.8% of revenues last year. The year-over-year decline in operating margin was driven by lower COVID-19 testing revenue, partially offset by the recovery in our base business. Reported EPS was $4.02 in the quarter, compared to $4.14 a year ago. Adjusted EPS was $3.96 compared to $4.31 last year. Cash provided by operations was $1.75 billion through September, year-to-date, versus $1.46 billion in the same period last year. Turning to guidance, we have raised our full-year 2021 outlook as follows: Revenue is expected to be between $10.45 and $10.6 billion, an increase of approximately 11% to 12% versus the prior year. Reported EPS expected to be in the range of $4.69 and $15.09, and adjusted EPS to be in the range of $13.50 and $13.90. Cash provided by operations is expected to be approximately $2.2 billion, and capital expenditures are expected to be approximately $400 million. Before concluding, I'll touch on some assumptions embedded in our updated outlook. We expect COVID-19 molecular volumes to continue to decline from Q3 levels throughout the remainder of the year. At the low end of our outlook, we assume approximately 50,000 molecular tests per day in Q4, and serology volumes to hold relatively steady at approximately 5,000 tests per day. As you may know, late last week, the public health emergency was again extended another 90 days through late January. We expect reimbursements of clinical COVID-19 molecular testing to hold relatively steady through the remainder of the year. However, we continue to assume average reimbursements to trend lower in Q4 as our mix of COVID-19 molecular volumes potentially shifts from clinical diagnostic testing to more return-to-life surveillance testing. Finally, we continue to assume low single-digit revenue growth in our base business in Q4 versus 2019. Getting to the midpoint or higher end of our outlook ranges assumes stronger COVID-19 molecular testing volumes and/or stronger growth in our base business. I will now turn it back to Steve.

Steve Rusckowski, CEO

Thanks, Mark. Well, to summarize, we had a strong third quarter. We have raised our outlook for the remainder of the year based on higher-than-anticipated COVID-19 volumes, as well as our continued progress we expect to see in our base business. And finally, the momentum of our base business positions us to deliver the 2022 outlook we shared at our March Investor Day. So, now we'd be happy to take any of your questions. Operator?

Operator, Operator

Thank you. We will now open it 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. Our first question comes from Kevin Caliendo, UBS. Your line is now open.

Steve Rusckowski, CEO

Good morning, Kevin.

Kevin Caliendo, Analyst

Thank you. Thanks. Good morning, everybody. Thanks for all the details and the guidance for '21. I really want to talk about into 2022, and sort of you reiterated your guidance from March, which I believe it was at the higher end of the $7.40 to $8.00 range. And I'm just wondering at this point, what are the assumptions baked in for COVID testing into next year? Do you anticipate that it's going to continue? Do you anticipate there's going to be a meaningful decline? Any color around how you think COVID testing will proceed into next year?

Mark Guinan, CFO

Sure. And, Kevin, just to be clear upfront, we haven't provided guidance yet for 2022; we provided an outlook. And we did confirm that today. And things have largely played out where we saw them for 2022, back in March, and base volumes have recovered. And we thought we were ahead in June, when it was close to being flat to 2019, and potentially saw some upside, obviously, with Delta, it took a little bit of a step back. But we still expect to enter 2022 with a base volume utilization level similar to pre-pandemic, so that's good. The second thing is we did assume that COVID will continue at a much lower level than we saw in '20 and '21, but still to be significant, and certainly much larger than our current flu testing. And we've referenced, in the past, that at some point COVID testing will still be here, but maybe more on the level of flu testing. At this point, we feel comfortable with what we had assumed back in March, around the continued need for COVID testing for PCR. And we envision a stronger role for serology going into 2022, and think that's a potential. So, we feel good about that. And then, we did reference inflationary pressures. We certainly have longer-term contracts on a lot of our purchases, but things like fuel certainly were subject to inflation in the near term and going into 2022. And then most notably, as many have talked, there's certainly inflation in wages and benefits, especially in wages. And that, as we look at that, we gave a range, and we still feel very comfortable that when you put all those pieces together, that the $8.5 billion baseline for revenue and the $7.40 to $8.00 is certainly still deliverable, maybe in slightly different way, but still very comfortable, that that's likely where we're going to land when we do finally provide guidance for 2022.

Kevin Caliendo, Analyst

Just as a quick follow-up, can you in any way quantify the higher inflationary pressures, supply chain, any of that? Is there any way to put numbers around that?

Mark Guinan, CFO

Yes. So, I'm sure you're most interested in 2022, so, we'll see what we can provide when we come out with guidance, in early next year, to provide clarity. Certainly at this point, we're experiencing some of that given the performance of the business; it hasn't prevented us from significantly over-delivering our previous guidance. So, we'll take a note of consideration, Kevin. We appreciate the question. We'll see what we can do when we talk more about next year.

Shawn Bevec, Vice President of Investor Relations

Operator, next question?

Operator, Operator

Yes, our next question comes from Brian Tanquilut, Jefferies. Your line is now open.

Brian Tanquilut, Analyst

Hey, good morning, guys. Congrats on the quarter. So, just a follow-up just as I think about costs and all the moving pieces. Obviously, the Clifton lab just opened. So, how are you thinking about the flow-through of the benefits from that and how it would potentially offset some of the inflationary pressures that you're seeing on the cost side?

Steve Rusckowski, CEO

Thank you for the question, Brian. As mentioned in our prepared remarks, we have been following our two-point strategy for some time now. The second strategy focuses on driving operational excellence, and we believe we can achieve ongoing efficiency gains of 3%. This 3% is derived from various programs within Quest Diagnostics, including the initiatives we implemented in Clifton. I also highlighted other programs during our prepared remarks, such as collaborating with suppliers on new integrated platforms and advancements in immunoassay and analysis. These are just a few examples of the efficiency gains we expect to achieve. Importantly, these improvements do not involve cost-cutting; rather, they enhance our operations, leading to better quality and service performance. The progress is evident in our numbers this year and will continue into 2022. These efficiencies have historically helped us counteract headwinds, and while we face challenges such as rising wage costs and pricing pressures, we have managed to offset these impacts. We anticipate similar headwinds in 2022 but are confident in our ability to address them, including any inflationary pressures. We remain committed to delivering on our outlook.

Mark Guinan, CFO

Yes, I just wanted to add a reference that the Clifton lab and its increased productivity efficiency is really part of our invigorate work that we talk about 3% productivity every year. It's not over and above or separate whatever common is that what we've done there like we did up in Massachusetts. We have added more automation. Obviously, as you add automation, you insulate yourself a little bit from labor inflation. So, certainly, we have that going as we operate that lab, but it is built-in, and part of what my assumptions I had putting together that outlook for 2022 that we would achieve that ongoing 3% efficiency is not something specially…

Brian Tanquilut, Analyst

Awesome. Thank you.

Operator, Operator

Our next question comes from Ricky Goldwasser, Morgan Stanley. Your line is now open.

Steve Rusckowski, CEO

Good morning, Ricky.

Ricky Goldwasser, Analyst

Hi, good morning. So, one follow-up question on the cost, I mean, clearly we're all interested in a magnitude of the potential impact of paper and inflation. So, maybe you can help us by reminding us what percent of your cost structure today is labor and how should we think about it breakdown between cost of goods and SG&A?

Mark Guinan, CFO

Yes. So, Ricky, we've shared in the past pre-pandemic, that about $3 billion of our costs was related to salary and benefits. Obviously, with COVID moving around it's hard to cite the precise number with including the COVID testing. So, I think that should give you a pretty good idea of what proportion of our costs a $6 plus billion cost base we had prior to the pandemic has made up the labor at somewhere in the 50% range. And then as we said, as we continue to automate that certainly offsets some of that, but also we are seeing an increased amount of demand for phlebotomy. So, that is going the other direction. We obviously considered a net benefit because giving access helps us grow our business and certainly makes us more attractive, especially in a world of consumerism. And it's a good thing, but it certainly will drive costs, the labor costs as a percentage of all costs in the other direction.

Ricky Goldwasser, Analyst

And then just a follow-up on the direct-to-consumer point, Steve, you mentioned a soft launch of a comprehensive health plan, all that's directed to consumer. Can you just share with us what has been the response to date and maybe some data points about pricing?

Steve Rusckowski, CEO

Sure. So, as I said in my introductory remarks, we have a product that we sold for years to employers called Blueprint for Wellness. And we offer it to Quest employees as well. So, it's a fabulous dipstick reading on an annual basis for people to get an indication of what's going on with their health. And if we do it year upon year, you've got a good nice trending capability that I found beneficial since I've been here in question, I know many of our employees have as well and many of our customers. So, we're now using that as the product to introduce that through our direct-to-consumer channel QuestDirect. We're very optimistic about the possibility that this has we believe that it has a unique capability that few others provide. And we also believe it's hitting the market at the right time, where many people have not gone to their primary health care providers. And we believe that there's a lot of opportunities now for people to directly engage with us as a consumer to buy this directly from us. As far as pricing, Mark can share what we're thinking about in terms of pricing, even though this is a soft launch.

Mark Guinan, CFO

Yes. So, it's going to be a couple of hundred dollars. And when you look at the individual elements that are contained in here, it's a reasonable price for everything that you get. And I can also tell you that we've gotten a lot of feedback that this score that we give people with really simplifies how to interpret the results is a huge consumer positive. So, a lot of reason to believe that this could get some additional momentum for our consumer business, and we think the pricing is reasonable and we feel that the product we're delivering is something that consumers really find interesting and valuable.

Steve Rusckowski, CEO

And just to follow-up on the price, we actually did some market research to understand that the value that this provides to consumers justifies the price that we're pricing it for initially. So, we feel good about value delivered and price charged.

Shawn Bevec, Vice President of Investor Relations

Operator, next question?

Operator, Operator

Our next question comes from Jack Meehan, Nephron Research. Your line is now open.

Steve Rusckowski, CEO

Hey, good morning, Jack.

Jack Meehan, Analyst

Good morning, Steve. Good morning, Mark and Shawn. I wanted to continue on the inflation topic, but looked at a different way. If operating costs were to remain elevated, do you think there's an appreciation by payers that the cost of doing business is moving higher? How do you feel about your ability to get price increases? Maybe just talk about recent negotiations.

Steve Rusckowski, CEO

Yes, let me start by saying that we've been working hard to show our health plan partners that we continue to deliver value, and I believe we are making significant progress. One aspect is that we are gaining access to more lives; currently, 90% of insured lives in the United States are within our network, and we are optimistic about adding more this coming year. Additionally, regarding pricing, we are actively reviewing our contracts as they come up for renewal. As mentioned in previous calls, we believe our pricing is competitive, and we offer great quality and service, which has allowed us to be included in preferred lab networks. We are receiving some modest price increases, and we believe that as we move forward, we will continue to advocate for these increases. Like everyone else in this new inflationary period, our costs are rising, so we need to consider discussing modest price increases going forward. Mark, do you have anything to add?

Mark Guinan, CFO

Yes, Jack, I think many people understand that our health plan contracts usually last three to five years. Not every health plan contract is up for renegotiation at the same time. We've been discussing PAMA and how it's shifting the situation, allowing plans to consider NLA rates and ensuring they maintain competitive rates because they are aware of the independent labs market, which we’ve noted is lower than the market overall. The tradition of pricing below Medicare is changing with PAMA. In light of inflation, which you've mentioned, it's definitely part of our discussions in recent months. I can tell you that, although nothing is finalized yet, there is one national payer we've been negotiating with that seems likely to give us our first price increase in my tenure, which has been over a decade. We’re stabilizing our commercial negotiations from a pattern of declining prices with each contract extension to a more flat approach. We've also mentioned several regional plans where we've seen increases in the past couple of years. Now, we have this national contract, and I'm very hopeful for an increase. I can’t specify how much of the potential increase is due to inflation, PAMA, or our value proposition, but we are certainly in a much better situation.

Steve Rusckowski, CEO

Just to remind everyone, our health plan channel business is a significant portion of our revenue every year. But what we've also highlighted, the reason why we do have unit price decreases and our typical assumptions annually is because we have other pressures in our business. We do have break business to physicians, which we call clients and our client business as under price pressure over the past several years. And that has contributed to the price pressure we see. Secondly, as we sell to hospitals and we're doing quite well in the hospital segment, but it is price competitive. And then we have other product lines, where we sell our services directly to employers or to insurance companies is price pressure there as well. So, when we talk about our unit price changes, it's not all in the commercial health plan area. There's other areas that we have price pressures as well.

Operator, Operator

Our next question comes from A.J. Rice, Credit Suisse. Your line is now open.

A.J. Rice, Analyst

Thanks, everyone. I’d like to ask a broad question about how the pandemic might affect your business in the long run. During the pandemic, it seems people have shifted away from traditional doctor visits to virtual care and other options for primary care. Are you noticing this trend, and does it benefit or hinder your operations if people choose these alternatives? Do you believe you can capture a significant portion of that demand? Additionally, regarding the pandemic, you mentioned that if you experience strong performance due to COVID testing, you've expedited some of your cost-saving and efficiency programs. Should we see this as simply improving your visibility on the 3% annual cost reduction target, or are there initiatives in place that could lead to even more advantages in 2022 and thereafter?

Steve Rusckowski, CEO

Yes. So, thanks A.J. for your question. Let me take the first one, I'll ask Mark to comment on the second part of your question. First of all, telehealth as we all know has really increased considerably during the pandemic and it has really hit an inflection point in in-patients and consumers are now very comfortable with getting a portion of their healthcare delivered through telehealth networks, whatever that might be. And as we have watched it initially, a lot of the telehealth visits started with mental health and behavioral health and have now transitioned to more general health and primary care and even specialized care. So, with all those visits happening in telehealth, you have to engage with the patient and have to be able to enter orders. And unfortunately for us, despite the pandemic and before the pandemic, we have strong relationships with all the telehealth companies. And as you would expect, they're only going to work for us with a small group of laboratories. Quest would be one of those laboratories. So, we're very well positioned with the telehealth providers, but you also know that even though there are telehealth companies, telehealth is provided through integrated delivery systems, hospital systems in different ways, and they might use one of the telehealth provider platforms, but they're still providing that through their physicians and using their EMR. And so, when they enter the order, it's going to be into the order of the same way as in the past. So, we're watching it carefully. We do believe it's a positive trend for us given what I just described, but it's complicated because it all depends how telehealth platforms are deployed in particular with so many on physicians by integrated delivery systems. And they're still conducting the business as they do. It all depends how they actually implement their telehealth services throughout their network and how that will affect our business. But again, for us, we believe it is a positive. So Mark, do you want to take the second part?

Mark Guinan, CFO

Yes, actually, A.J. could you repeat the second part?

Steve Rusckowski, CEO

It had to do it accelerating our drive program because of our enhanced performance. And I think he's speaking to some of the acceleration in capital purchases that we've made and spending some additional money to get more improvements than what we would have realized if we didn't have the pandemic. A.J. is that a correct…

Mark Guinan, CFO

We have been able to invest more than we expected due to stronger growth in 2021. A significant portion of this investment is aimed at enhancing our top line. We have discussed our efforts in advanced diagnostics and building a consumer business. Consequently, most of our opportunities have been focused on top line growth while balancing short-term results with long-term value creation. Additionally, reflecting on the investments made during the pandemic, we have the chance to update our molecular equipment to more efficient and advanced models, which will lead to greater efficiency than we would typically achieve. However, I am not currently ready to commit to more than a 3% productivity increase, as even small changes in this area are quite significant. Overall, I believe the pandemic has facilitated value creation and additional cash that has allowed us to speed up some investments, primarily focused on top line growth, but there have also been improvements in productivity.

Operator, Operator

Next up is Ann Hynes, Mizuho Securities. Your line is now open.

Ann Hynes, Analyst

Hi, good morning. So, I just want to talk about the base volume trends. I know revenue was up versus 2019, but can you give us some color on how much your based volume trends are still down versus pre-pandemic, maybe ex some of the PLS deals that you've signed during the pandemic, and if it's still down maybe just to give a geographic breakdown and I guess my second question would be obviously testing was a very strong for molecular PCR tests for COVID-19. Can you give us a breakdown, how much of that was contributed to like this back to life initiative, whether it's schools, cities, states more like maintenance testing, and I know you said in your prepared remarks that you assume revenue per test goes down in Q4. Can you give us what it was in Q3 and maybe just directionally what we should model for Q4? That would be very helpful. Thanks.

Mark Guinan, CFO

Okay. Thanks, Ann. Mark, why don't you just start with giving the numbers on base business performance system there. Yes. So, hopefully, I can clarify, base volume in total is obviously anything on COVID-related as we've been through the pandemic, we've been recording strong growth in base volume, which includes our M&A and our PLS, as you would expect. But we've also been trying to provide some color on utilization, in the absence of independence way to measure that. We look at our base volume ex, the acquired volume and facts the new PLS deals. And we've talked about that continuing to improve in addition to the growth we're getting from M&A and from PLS. So, in June, the organic base volumes and the new PLS deal was getting close to back to the 2019 levels. And then it kind of stabilized in August – in July, and it took a little bit of a step in August. And then as we see where we are through September and into October, it's getting back again, very close to being fully recovered in 2019. And that's why I said earlier that we would expect certainly by the end of this year and going into '22 that we'd be fully recovered. Now, it is regionally very variable as we've talked in the past, and that really has not changed. There are certain regions that are actually above where they were in 2019, most notably our Southwest region, as we're looking at Florida in the south; the volume trends are above, and then a couple other areas that are kind of in that middle point. And then the one area of note that's really been lagging is the east, and it continues to lag while it certainly has improved from where it was several months ago. It's still down and kind of an outlier especially in the five boroughs of New York City. And then quickly, I'll answer the question on the revenue expectations for molecular testing, and I'll let Steve talk about the back to life. So, we're still around $90 in the quarter. We're not expecting a meaningful decline in the fourth quarter. Certainly, if back to life really, really took off, which is not, what we're expecting in the middle of our guidance here, it could have a little bit of a row, but again, it's still net positive. It's just math. So, you can expect for your modeling purposes, that just a very, very slight decline in Q4, nothing of significance.

Steve Rusckowski, CEO

And the last question Ann, you had asked for the breakdown of what we describe is, first of all, the clinical portion of our PCR volumes versus return to life portion of our clinical volumes. And as you can expect, it's tough for us to know exactly particularly, which bucket we can put those in. But I can tell you that the trend line is trending towards more of the return to life. We see the infection rates coming down and we see programs that we've worked on going up, examples are the return to school programs, we mentioned 20 states and five more coming. We also doing some testing for employers if they have mandates in place where they're requiring vaccination or testing. So, we'll see some increase in testing related to again, employers bringing people back to the workplace and requiring testing or vaccination for that. So, I would say trending wise, it is a larger percentage than before, but it's very difficult for us to give you exact numbers on that because we just don't get it through the orders that we received. But we think what we've provided for guidance is clearly what's going to happen in '22.

Operator, Operator

Next up is Ralph Giacobbe with Citi. Your line is now open.

Ralph Giacobbe, Analyst

Hey, good morning. Thanks. First, just a quick follow-up on a comment you made, can you give us a sense of how much flu testing you do a year if that's what you're anchoring for baseline COVID testing going forward. And then separately, I was just hoping you could talk about COVID reimbursement and the outlook of that for next year? Obviously, you mentioned PHG got extended at least for the early part of next year, if that continues to expand, if you expect reimbursement to be better than what you assumed in that $8 EPS for next year? And then also, what about commercial pricing specifically for COVID is that tied to PHG? Or help us understand sort of how that's negotiated and if there's a step down there for next year? Thanks.

Mark Guinan, CFO

Yes. So, it was quite a bit there, Ralph, we'll see if we can touch on all of them. So, we don't generally share the precise revenue for any given test offering, but it's significantly lower than our current levels of COVID and what we would anticipate. So, the flu is not the baseline for 2022. We still expect COVID testing to be multiples of our flu revenues in 2022. And the reason flu testing is smaller than what the otherwise is, there's not a ton of molecular testing done. Physicians have become very comfortable with doing point of care. And even though the molecular is more precise, they feel that it gets good enough in the office and they have an opportunity to make money on it. So, I would probably be several years, although I don't have the ability to call it precisely before we would expect COVID to be at our flu level. And then in terms of the pricing we have either specific agreements or general agreements that as long as the federal health emergency continues that the pricing will reflect what we're being paid by the federal government. So, it's not mechanistically tied to every contract, but we know that the expectation would be when that goes away. And again, there's still always a possibility they can decouple that $100 reimbursement rates from the health emergency. So, there's some other risks as well, but as long as that continues, we would expect most of our commercial pricing to be at the same rate. And then, obviously, when that goes away, that we would expect negotiations to take it down to more the NLA level. So, when I talked about 2022 at the Investor Day, I talked about a reimbursement rate around $50, which is what the NLA is. And so, again, when you put all these pieces together, I want to be clear, we still fully expect to be in the upper end of that $7.40 and $8. I just wanted to caution against upside to that given everything that's going on with inflation and so on, because we do have some positive things that have developed over the last six months or so. And some of that is probably going to be partially offset if not largely offset by labor inflation. So, we're still pretty much where we were back in March, so in the higher end of the $7.48, and then certainly at least $8.5 billion of revenue, which importantly ties back to the 2018 CAGR that we've shared with you at Investor Day, and so just getting there in a little different way, but still getting to where we said we would be.

Operator, Operator

Next question comes from Matt Larew, William Blair. Your line is now open.

Steve Rusckowski, CEO

Good morning, Matt.

Matt Larew, Analyst

Yes. Hi, good morning. So, a number of questions around labor issues, I actually want to ask about supply chain. I'm just curious if you're starting to see any challenges in sourcing anything, either for your PSCs or the labs, either longer lead times, and then if you're having any issues with the sample transport logistics?

Steve Rusckowski, CEO

Well, so far Matt we're keeping up, we always have battles here and there, even despite the pandemic with supplies got a complicated business and a lot of pieces have to come together to do what we do, but not a meaningful disruption so far, but we're watching it carefully because we're not through this yet. So, the last part of this is around logistics and again, logistics have become a little more complicated given we do use commercial carriers for some portion of our logistics, but we've been managing our way through that. Fortunately, we have our own network of carriers. We have about 3,500 carriers and automobiles that are request employees. We have a fleet of small airplanes through some of the connections between our collection locations and our laboratories and they're employed by us. And so we're happy we had those in these uncertain times and we continue to have strong relationships with the national carriers as well, so far so good.

Operator, Operator

Next up is Pito Chickering, Deutsche Bank. Your line is now open.

Pito Chickering, Analyst

Hi, Peter.

Steve Rusckowski, CEO

Hey, good morning, Pito.

Pito Chickering, Analyst

Hi, good morning guys. I follow-up on Ann's question around the base testing business, once you exclude M&A and POS, can you give us color on where the tests are coming in from specifically looking at primary care visits versus specialty visit versus hospital visits? Just curious if hospitals slowdown in the fourth quarter with the COVID surge, does it impact anything on your fourth quarter growth?

Steve Rusckowski, CEO

Yes. First, to clarify, the utilization trend I mentioned, which is nearly fully recovered, does not include all points of service. Since we are comparing to 2019, it omits some of the larger recent deals to avoid skewing our understanding of utilization. We had a significant PLS business in 2019, and I am including that as part of the trend. The recovery we have seen has been widespread, without many differences among areas. Early in the pandemic, we noted some lagging sectors like drug monitoring, primarily due to policy issues, which have largely been addressed. The toxicology and prescription drug monitoring business is now recovering similarly to other clinical areas. Hospitals rebounded quickly in the early pandemic as they resumed elective surgeries, while physician offices lagged a bit. However, currently, as we mentioned in our prepared remarks, the physician business is robust, with volumes in some regions exceeding those of 2019. Aside from the East, we do not perceive any fundamental shifts in patient engagement with physician offices or in prescribing practices for our diagnostics business.

Operator, Operator

Next up is Tycho Peterson, JPMorgan. Your line is now open.

Steve Rusckowski, CEO

Hi, Tycho.

Unidentified Analyst, Analyst

Hi, this is Casey on for Tycho. Two quick ones for you guys, the first one, do you think that the increased cash spent per requisition or test density trends that you've called out in 2021 will continue into 2022? And is that baked into that $7.40 to $8 EPS outlook. And then my second one is just on capital deployment. You guys have completed the ASR, right? So should we expect any more buybacks in 4Q and what share account should we use for our model for 4Q? Thank you.

Steve Rusckowski, CEO

Yes, I'll take the first one. Mark, you take the second and versus on rec density that is the number of tests per requisition. We assume there's a lot of different moving parts as you know for our business. One of which is the mix of tests. The second is number of tests for requisition being able to we have channel mix changes. So, all of that is complicated in our outlook that we've provided. So, we assume that that's in there. And Mark, you want to talk about capital deployment question?

Mark Guinan, CFO

Sure. So, the ASR should be wrapped up sometime in the next 30 days. So, therefore for at this point, even if we did additional purchases once the window opens and not committing to anything at this point, because we always say there's a balance between potential M&A and share repurchases. It wouldn't have a significant impact on our way so this year. So, any sort of additional purchases of our shares repurchases would be more of an impact for 2022. And obviously, we'll talk about that in detail when we come up to the guidance for 2022 early next year.

Operator, Operator

Next up is Derik De Bruin, Bank of America. Your line is now open.

Steve Rusckowski, CEO

Good morning, Derik.

Unidentified Analyst, Analyst

Hi, this is on for Derek. I wanted to dig into the base business growth specifically within your advanced diagnostic business. Was there any notable trend for cancer and genetic testing, if you could comment on the growth trajectory that'd be great?

Steve Rusckowski, CEO

John, in our remarks, we're pleased with the recovery we've seen in advanced diagnostics and remind everyone that our definition of advanced diagnostics are entirely molecular and genetics. And when I say recovery and I did say molecular, it does not include our COVID testing. So, it's our base, if you will, molecular and genetic testing. And we saw very good growth in beyond recovery for our prenatal testing feel good about that. And we are seeing nice growth for our genetics business. And as you recall, we did an acquisition with blueprint genetics last year, and that's progressing nicely and give us some nice growth and strength in that business. So, we feel good about the recovery and growth we're seeing in those areas that we're really focused on and genetics in general is one of those areas.

Operator, Operator

Next up is Mike Newshel, Evercore ISI. Your line is now open.

Steve Rusckowski, CEO

Hey Mike.

Mike Newshel, Analyst

Hey, thanks. Do the labor and inflation cost issues you mentioned earlier affect your long-term growth targets for earnings beyond 2022?

Mark Guinan, CFO

Yes. At this point, we have a broad range, but like in previous periods, we will look for and identify offsets to these challenges. It is not significant enough for us to change our multi-year outlook, which forecasts earnings growth in the high-single digits. While we have identified various factors over the next several years, I am confident that as time progresses, we will find additional productivity opportunities to counterbalance some of these issues.

Operator, Operator

There are no more questions.

Steve Rusckowski, CEO

Okay, very good. So, thanks to everyone for joining our call today. We appreciate your continued support and everyone have a great day.

Operator, Operator

Thank you for participating in the Quest Diagnostics Third Quarter 2021 Conference Call. A transcript of prepared remarks on this call will be posted later today on Quest Diagnostics' Web site at www.questdiagnostics.com. A replay of the call may be accessed online at www.questdiagnostics.com/investor or by phone at 866-360-7722 for domestic callers or 203-369-0174 for international callers. Telephone replays will be available from approximately 10:30 a.m. Eastern Time on October 21, 2021, until midnight Eastern Time, November 4, 2021. Goodbye.