Ladies and gentlemen, welcome to HCA Healthcare 4th Quarter 2025 Earnings Conference Call. Today's call is being recorded. At this time, for opening remarks and introductions, I would like to turn the call over to Vice President of Investor Relations, Mr. Frank Morgan. Please go ahead, sir.

Good morning, and welcome to everyone on today's call. With me this morning is our CEO, Sam Hazen, and CFO, Mike Marks. Sam and Mike will provide some prepared remarks, and then we'll take questions. Before I turn the call over to Sam, let me remind everyone that should today's call contain any forward-looking statements, they're based on management's current expectations. Numerous risks, uncertainties, and other factors may cause actual results to differ materially from those that might be expressed today. More information on forward-looking statements and these factors are listed in today's press release and in our various SEC files. On this morning's call, we may reference measures such as adjusted EBITDA, which is a non-GAAP financial measure. A table providing supplemental information on adjusted EBITDA and reconciling net income attributable to ACA Healthcare, Inc. is included in today's release. This morning's call is being recorded and a replay of the call will be available later With that, I'll now turn the call over to Sam.

Good morning and thank you for joining the call. We closed out the year with strong results that were mostly consistent with the previous quarters in 2025. We delivered a 19th straight quarter of volume growth, reflecting continued solid demand across our markets. The benefit of network investments and improved results in capacity management, quality patient outcomes, and stakeholder engagement. Revenue increased 6.7% compared to the prior year quarter, and with disciplined expense management, margins improved both sequentially and year-over-year. Net income attributable to HCA Healthcare increased almost 31%. Diluted earnings per share as adjusted increased 29%, and adjusted EBITDA increased around 11% versus the prior year. Reflecting on 2025, this was another successful year for HCA Healthcare. Throughout the year, our teams executed at a high level. We gained ground with our strategic agenda, and we stayed focused on the fundamentals. Additionally, we invested significantly in network expansion clinical capabilities. These investments helped deliver positive outcomes across the HCA Healthcare system. As a result, our networks had approximately 47 million patient encounters during the year, representing a record level of patient care activity for the company. I want to thank my colleagues for their outstanding work, their dedication to our patients, and their unyielding commitment to our mission. Now let me transition to the policy environment. We continue to monitor several policy matters, including the expired enhanced premium tax credits, the ongoing developments related to Medicaid supplemental payment programs, and the rural health transformation program. These matters continue to evolve. As we learn more, we will provide updates at the appropriate times. That said, we believe our core business remains strong with forecasted volumes in our long-term 2% to 3% growth. For the past year, we strengthened the company's resiliency program in three important areas, and this gives us confidence that we can navigate effectively through these policy dynamics. The first was organizational. In this area, we added new capabilities that were aligned around the company's operating imperatives. Next, we strengthened the management systems to enhance execution. And lastly, we ramped up leadership. The second area relates to competitive positioning. We increased hospital capacity, clinical service offerings, and outpatient facilities across our networks to create greater patient access and address the needs of our communities. The third was financial. Here, we advanced our cost management agenda and improved our balance sheet with strong cash flow and disciplined capital allocation. These results allowed us to invest significantly in our networks, our people, and our AI and tech agenda. In closing, we are well positioned to move forward as we begin 2026. We continue to believe the HCA way of combining high-quality local provider networks with the distinct capabilities, talent, and scale of a national healthcare system creates sustained value for our stakeholders and allows us to deliver more effectively on our mission. With that, I will turn over the call to Mike for more details on the quarter and our outlook for 2026.

Thank you, Sam, and good morning, everyone. We were pleased with results of the fourth quarter of 2025, which reflected strong operational performance combined with distance and capital allocation. Let me note some same facility volume comparison to fourth quarter of 2025 versus fourth quarter of 2024. Admissions increased 2.4%, and equivalent admissions increased 2.5%, in line with our expectations of 2% to 3% growth. Inpatient surgeries were flat, and outpatient surgical volume was down slightly. DR visits increased to 50 basis points. Overall respiratory volumes had no material impact on year-over-year volume. Regarding payer mix report, same facility total commercial equivalent admissions increased 1.1% over the prior year, with exchanges growing 2.5% and commercial excluding exchanges increasing increasing approximately 1%. Medicare increased 3.5% and Medicaid increased 2.2%. Same facility net revenue for acquittal and admission increased 2.9% versus... The 80 basis point improvement in adjusted EBITDA margin in the quarter was driven primarily by solid revenue growth, good results in labor management, and improvements in other operating expenses. Adjusted EBITDA grew approximately 11% compared to the prior year quarter, primarily due to strong operating performance and an approximate $150 million increase in our hurricane markets. As we've said in the past, Medicaid supplemental payment programs are complex, variable in timing, and do not fully cover our costs to treat Medicaid patients. Due to a retro payment from Virginia in the fourth quarter, the net impact of supplemental payments was approximately flat versus prior year quarter. Now let me discuss full year results for 2025, which reflected good demand growth in our markets. On the same facility basis, we posted growth in revenue of 6.6%, equivalent emissions of 2.4%, and net revenue per equivalent emission of 4.1% versus prior year. Consolidated adjusted EBITDA increased 12.1% and over a prior year, and we delivered a 90 basis point improvement in adjusted EBITDA margins. The net benefit from supplemental payments increased by $420 million. Hurricane impacted markets contributed approximately $125 billion in adjusted EBITDA growth. Deluded earnings per share as adjusted increased 28.5%. Moving to capital allocation, capital expenditures totaled $1.5 billion in a quarter and $4.9 billion for the year. Additionally, we purchased $2.6 billion of our outstanding shares during the quarter and $10 billion in the year. We paid $162 million in dividends for the quarter and $679 million for the year. Cash flow from operations was $2.4 billion in the quarter and $12.6 billion for the year. This represents a 20% increase in operating cash flow in 2025 over full year 2024. Our debt to adjusted EBITDA leverage remained at the low end of our target range. Given our strong balance sheet, we are well positioned for the future. So with that, let me speak to our 2026 guidance. We expect revenues to range between $76.5 billion and $80 billion. We expect adjusted EBITDA to range between $15.55 billion and $16.45 billion. We expect net income attributable to HCA Health Care to range between $6.5 billion and $7 billion. We expect diluted earnings per share to range between $29.10 and $31.50. Further, we continue to see opportunities to deploy capital and drive organic growth in our markets through investing in high-acuity programs, increasing our network through new access points, and building new inpatient capacity. As a result of these opportunities, we have increased our capital spending range from $5 billion to $5.5 billion. Our 2026 guidance includes the following assumptions. Growth in equivalent admissions between 2% and 3%. Adverse impact on adjusted EBITDA between $600 million and $900 million related to the health insurance exchanges. This includes impact from administrative reforms enacted in 2025, the One Big Beautiful Bill Act, and the expiration of the enhanced premium tax credits. We expect an offset to this exchange headwind of approximately $400 million through resiliency initiatives designed to generate efficiencies throughout the organization. We anticipate decline in supplemental payment programs' net benefit between $250 million and $450 million. The expected decline in net benefit is driven primarily by Tennessee's program reverting back to four quarters of net benefit versus six quarters in 2025, a pause on one specific program in Texas, and a one-time retro payment from Virginia. This guidance does not include any potential impact in 2026 from additional approvals of grandfathered applications. We do not anticipate any significant growth through adjusted EBITDA from our hurricane impacted markets over prior years. We expect four-year margins to be slightly above 20%, consistent with 2025, and cash flow from operations to range between $12 billion and $13 billion. Lastly, we plan to continue investing in our technology and digital innovation strategies, which we expect will deliver long-term value and help position the company. Considering these factors, our overall 2026 adjusted EBITDA guidance reflects strength and momentum in operations, increased investment in strategic initiatives, consistent business fundamentals, and a disciplined approach to capital allocation. Given what we see today, including the demand in our markets, our resiliency program, and our digital transformation initiatives, we remain comfortable that we will perform within our long-term plan. As noted in our release this morning, our Board of Directors have authorized a new $10 billion share of purchase program. We currently anticipate completing a majority of the existing authorization in 2026, subject to market conditions and other factors. In addition, our board declared an increase in our core lead dividend from $0.72 to $0.78. In conclusion, 2025 marked another year of solid operational performance for HPA, and we believe that we are well positioned for continued progress and success in 2026. With that, I will turn the call over to Frank for questions.

As a reminder, please limit yourself to one question so we might give as many as possible. I may now give instructions to those who would like to answer the question.

Thank you. We will now begin the question and answer session. If you would like to ask a question, please press star, then the number one on your telephone keypad to raise your hand and enter the queue. If you would like to withdraw your question at any time, simply press star one again. Your first question comes from the line of A.J. Rice with UBS. Your line is open.

Hi, everybody. All right, and thanks for the comments and the detailed commentary on the guidance. I wondered maybe if the focus is on the top line, of course, in your comments, can you talk about the expense items, SWV supplies, other operating expenses, professional fees, et cetera, what are your underlying assumptions there that are embedded in the guidance? Is there margin improvement opportunities on any of those lines in 26?

Good morning, A.J. When I look at the margin, and I noted this in my comments, but the midpoint of our revenue and adjusted EBITDA guidance range suggests expectations for pretty stable margins in 26 for stable trends in our operating costs. I might note that we do see and would expect continued physician cost pressures and believe that those could even be maybe in the high single digits of growth in 26 versus 26. So those would be kind of some comments on the cost side of our guidance.

Okay. And contract labor and just general labor, that's steady year-to-year is the underlying assumption?

It is. I mean, the only thing I might mention is that a contract labor as a percent of SWB, you know, we came in at about 4.2% for the fourth quarter. And that feels like, you know, kind of our run right now as we come into But other than that, I mean, the resiliency plan is reflected in our guidance, as I noted in my comments, and, you know, largely the resiliency plan is much of the, you see that in our guidance as well, and I think it reflects, you know, really strong cost and operating leverage as we head into 2026.

Okay, great. Thanks so much.

Your next question comes from the line of Anne Hines with Mizuho. The line is open.

Great. So it sounds like the net negative headwind from ACA subsidies is in the $200 to $500 million range. Can you just go into more of the resiliency programs, provide some more detail on what's making up that $400 million, and obviously the confidence and executing throughout the year just from a timing perspective and when you expect to lose potential volume?

The resiliency, and I'll pick up the second day's changes. But, you know, as we've talked about over the last really year plus, we have been implementing steps to try to mitigate the impact of this health insurance exchange headwind. We've been working to both enhance and accelerate our financial resiliency program. I would make a couple of contextual notes related to our program. The first is that our program has four key areas of focus, revenue integrity, variable and fixed cost efficiencies, and we are leveraging three primary capabilities in driving our financial resiliency program. First, internal and external benchmarking and advanced analytics. Second, digital transformation with AI and automation. And third, expanding and leveraging our shared service platforms. Our 2026 plan includes significant efforts, service platforms, and in our hospital operation, and elements to drive better capacity management, including managing throughput and length of stay in our inpatient settings, in our emergency rooms, in our operating rooms. On the cost side, we have robust plans to drive labor efficiency, supply cost actions, and operating costs. A lot of our teams, Ann, I think they've done a wonderful job embracing resiliency, and we have confidence that we'll be able to. A little bit more on your question related to, let me just say this, you know, our estimated range, as I noted in my comments, of $600 to $900 million adverse impact to EBITDA, includes the potential impacts from administrative reforms that were passed as part of the One Big Beautiful Bill Act and enacted through rulemaking, as well as the expiration of the And so, as a reminder, of the decline in our HICS volumes, we assume approximately 15% to 20% migrating to uninsured, which includes a decline in utilization. From a timing perspective, we are, you know, watching the enrollment figures carefully. As you know, they were released recently by CMS, but the- Your next question comes from the line of Peto Chikorini with Deutsche Bank.

Your line is open.

25, $450 million to $900 million from HICS and supplemental payments offset by the resiliency programs. I just want to make sure that I'm calculating the core growth of what HCA is doing at sort of 3% to 12%, the 7% at the midpoint, 4% to 6%, so you're still guiding core above.

Let me say, I think, from a range perspective, that I would just reiterate two or three of the moving parts for clarity. You know, we've noted the range of potential adverse impact from the exchanges of $600 to $900 million. We've noted that we believe that the supplemental payments could have a $250 to $450 million decline in net benefit, and that that decline in net benefit does not include any potential new approvals or grandfathered applications by CMS. And lastly, resiliency, you know, we are confident that we'll be able to execute on our plans for 2026 given the $400 million target. So, I think in taking those kind of swing factors into account, Thio, we do agree, we're pleased with the strength and the performance of the company and the momentum of the company as we go into 2026. And any chance you can size up the potential D&E of all the approvals coming from Yeah, we're not sizing the potential approvals until we get a sense of the actual approval from CMS and what changes, if any, they make through their review and improvement processes. So, not quite sizing that yet.

Great. Thanks a lot.

Your next question comes on the line of Justin Lake with Wolf Research. Your line is open.

Hi. Thanks. This is Anna on for Justin. I just wanted to ask the $400 million of resiliency benefit in 26 is impressive. Can you talk about how much of that comes from ramping AI initiatives and how we should think about further resiliency opportunities beyond 2026 as some of the Medicaid cuts begin in the out years?

Yeah, and we've mentioned this before, but I think the way to think about a resiliency program is that it's a multi-year program. The $400 million came from our assessment of implementation status of the long list of opportunities that we're working on, and based on that assessment of our implementation It gave us confidence to include $400 million of savings in 26 versus 25 in our – as we move forward, we continue to work on our resiliency plan. It's a program, and I mentioned on the previous question, you know, components that we're working on, but we're really pleased with the depth and breadth of our resiliency program and believe that it gives us, you know, good support here as we move.

Your next question comes from the line of Witt Mayo with WeRink Partners. Your line is open.

Hey, thanks. You guys have been working on some digital efforts with payers recently, I think at least some of the large national ones around data and disputes. Can you maybe talk about that and how it's manifesting into, you know, revenue cycle, yield, collections, or pricing, or maybe just reduce payer friction?

Sure. Hey, Witt, thank you. We have, over the last year, have launched a series of engagements with many of our major payers. And these engagements kind of focus on digital integration, so think about, you know, electronic data exchange, think about the kinds of activities that ACA and our payers can partner on to produce administrative simplification. And I think they also include speed resolution to resolve disputes. You know, frankly, we continue to work with our payers to find ways to make things better for their members and our patients and to digitize the whole work flow between. I think overall, these engagements have produced good relationships between us and our payers.

And Mike, I speak to the working capital improvements this year, which are part and parcel to some of that, not entirely all of it, but I think that is reflected in the cash flow production that the company had, and then our working capital improved this year.

For sure. We had a nice reduction in net days in AR, especially in the fourth quarter.

That really reflects the benefit alluded to, the mature dynamic in our company around being cost effective, being high quality, and finding ways to improve from a process standpoint and a leveraged standpoint with our overall scale.

Your next question comes from the line of Brian Tanquillit with Jeffries. Your line is open.

Thank you, guys, and congrats on the coordinator of the guidance. Mike, as I think about just the rural benefit from one big, beautiful bill, I'm curious if you have any updated thoughts. Maybe they finalized some of the rules there, and then just any call-outs in Q1 that you're thinking about other than sort of the tough comps that we should be contemplating.

On the Rural Health Transformation Program, you know, under the 1B Beautiful Bill Act, you know, all 50 states have been allocated their program funding, but these are largely state-driven programs, and most of the details have not yet been released. We do not yet know the timing, the structure, or the size of any state-level awards or how much of the funding will be distributed within each state. So our approach, Brian, has been to really stay actively engaged with our state and federal partners regarding both the program design and then our response to program design to ensure that once the applications are open, that we will participate in a way that's At this stage, we do view the Rural Health Transformation Fund as a potential opportunity, but it's not something that we have reflected in our guidance given the remaining uncertainty. When I think about the quarter, you know, we had a strong quarter. You know, we noted that there's going to be one part of that that we anticipated. You may recall that on our third quarter update, we thought we would finish the full year at a $300 million net benefit based on payment program because we were anticipating a year over year decline in fourth quarter given some known headwinds. We ended up getting in the fourth quarter, which kind of pushed us flat in the quarter and led us up to a $420 million net benefit. That's the only thing I can think of, Brian, that would be a little different than we anticipated when we gave our update for guidance in our third quarter call. I mean, volumes came in largely where we anticipated were stable.

Overall, we deem- Add to the rural, we believe, our rural communities. Urgent care, so that's another vehicle. The third piece for us is workforce. Our graduate medical education programs, programs, even our nursing rotations with our Galen College of Nursing programs create opportunities for us to, we believe, participate in the programs, but as Mike said, we're having to work through roughly 20 different programs in our company to understand how those funds are going to be applied, but we do think we have elements of the company that are in rural America in a way that deserves funding through these programs. Thank you.

Your next question comes from the line of Ben Hendricks with RBC Capital Markets. Your line is open.

Thank you very much. I was wondering if you could provide some thoughts on the potential for a transition to a health savings account construct for the enhanced subsidies, assuming those funds go directly to customer HSAs, is there any initial thoughts you have on how that would impact your current assessment of the EPTC expiry headwinds, and then how should we think about the impact on uncompensated care if some patients have access to the funds but may not be purchasing insurance?

So, hey, Ben, good morning. Yeah, I think as you think about President Trump's healthcare plan announcement, I think I think the plan, as we understand it, was really, the themes seem to be including the insurance plan and accounting for pharmaceutical prices and increasing potentially changing the way that instead of exchanges with tax credits, maybe a little bit more related to cash coming into healthcare savings accounts. It's a little early to get a sense for what aspects of that plan will come to fruition. We're monitoring it, as you can imagine, close picks those up and so at this point it's a little early to try to size potential impacts related to those kinds of potential changes we're just going to see how they flow through Congress and see what comes but obviously we're monitoring it just like you are and we'll update we know your next question comes from the line of Matthew Gilmore with key bank your line is open hey thanks for the question I want to follow up on the exchange discussion for 26 can

Can you give us a sense for how the exchange reforms and the subsidy expirations will impact the volume outlook? I'm curious if there's a drag that's being absorbed within the 2% to 3% volume outlook from the exchange expiration, and can you also give us a sense for how you're thinking about the decline in utilization from folks that moved to uninshored within your outlook?

Modeling, and again, I think it's important to always start with context. You know, this model and these judgments are significant, and they're early. So, you know, part of our work as we go through the next days, weeks, and months will be to test these assumptions against our actual experience. And so, we're going to know more, Matthew, at the end of first quarter, into second quarter, and we will keep you updated as we learn more. But yes, I do think that the overall volume of the company, although it's within that range of 2% to 3%, has an impact here. Without the walkthrough of the map, and so I'll just go back through it, it's instructive. We contemplate a 15 to 20% decline in our HICS, and that this volume will migrate to either employee-sponsored insurance or to uninsured. Of the decline in our volume, we assume approximately 15 to 20% of those people will end up with employee-sponsored insurance coverage, which does carry a benefit. But the remaining will go to uninsured, and for the ones that go to uninsured, we do anticipate a decline in utilization from those individuals, and we believe that that decline is somewhere in the 30% of the health care service, the health care insurance, the only other thing I might mention with the exchange population is we find that they tend to utilize the emergency room in a way that's heavier, you know, that's the focus that would come.

Your next question comes from the line of Andrew Mock with Barclays, your line is open.

Hi, good morning. Outpatient surgery declined year over year on a negative comp and moderated from the previous quarter. Can you elaborate on what you saw there and if there are any payer categories you would call out, you know, driving some of that volume pressure?

You know, if I pull up, Adam, just outpatient surgery, let me just talk about outpatient in general first, and then we'll touch surgery. But overall, on the outpatient side, you know, we were pleased with our outpatient revenue growth, which actually grew at a rate higher than our inpatient revenue. Under, we kind of characterize our outpatient revenue into four categories. Emergency services, outpatient surgery, which includes both hospital-based and AFCs, our ambulatory platforms, which include physician clinics and urgent care clinics, and other hospital-based outpatient services, including cardiology. All four categories experienced solid revenue growth over a prior year. A couple of notes on outpatient. And our same facility cases were down about 50 basis points in fourth quarter over prior year, with hospitals being about flat and ASCs down about 1.5%. Payer mix, though, continued to be solid, with declines to prior year primarily driven by Medicaid. In addition to the payer mix environment, we saw a decline in lower intensity cases like ENT. So, as a result, we had good growth in that revenue and earnings that are inclusive above the hospitals and the ambulatory surgery center place.

Mike, let me just add to just the whole outpatient discussion. We continue to invest significantly in outpatient facility development. Just this past year, we added roughly 100 business units to our outpatient footprint across the company, and we find ourselves heading into 2026 and 2027 with significant again, capital in the pipeline that's geared towards, yes, some inpatient capacity and inpatient capabilities, but also quite a bit of outpatient development. Moreover, I would suggest that we have a better pipeline for acquisition opportunities inside of our outpatient footprint than we've seen in a few years, again, allowing us to complement the existing networks that we have. And so when we look at overall revenue production of the company, I think Mike in the fourth quarter our outpatient revenue as a percent of total was actually up on a year-over-year basis. Some of that is due to the components that Mike laid out, but it's also due to the fact that we're adding units at a greater pace than we are obviously our inpatient hospitals. And so the combination of that we think is important to our overall network resiliency. And by that, we mean creating an environment where patients have easier access into the HDA healthcare system, and our payers actually have better price points for their members such that they can get into the system with urgent care or physician clinic or an ambulatory surgery center in a manner that is most productive for them as a patient but also for their insurance company. So we're pretty excited about the overall construct that's evolving for our company. I think today we have about 2,700 outpatient facilities or so. That continues to grow, and we see that pushing toward our targets of, you know, 18 to 20 outpatient facilities per hospital as we finish out this decade. And that, again, will come through capital development and greenfield projects, but also acquisitions that make sense for us strategically. like.

Your next question comes from the line of Sarah James with Cantor Fitzgerald. Your line is open.

Hey everyone, it's Gabby on for Sarah. I just wanted to double click on the payer mix and if you can share any color on how it played out compared to your internal expectations, specifically Medicaid infecting positively for the first time in 2025 and if that's something you expect to persist. Thank you.

Yeah, good question. So when I think about four quarter volume and the composition, and I mentioned this in Paul. You know, I think on the exchange side, we had a two and a half percent growth. We were actually down a smidge sequentially. I think that really reflects a couple of things. One, and this also impacted Medicaid, of the Medicaid redetermination process in the prior year. So we think we have fully sunsetted that timeline in prior year, and so you saw less exchange growth, and you also saw a bit more Medicaid volume. In Medicaid, 2.2% growth over prior year seems to be now back to kind of a normal growth rate, more consistent with our overall volume. The healthcare changes, you know, clearly we did not see a pull forward of demand, meeting premium increases, but, you know, the 2.5% growth we do believe reflects that timing of the Medicaid redetermination process. I think, you know, we were generally pleased with our payer mix in the quarter and our overall volume growth. I mean, Medicare up three and a half on admissions.

Your next question comes from the line of Ryan Langston with TD Cowan. Your line is open.

Good morning. I guess with the balance sheet in a pretty good place and maybe fair to expect smaller hospitals and health systems seeing more detrimental impact from subsidy expiration and impacts from the 1BBB, I guess now that the subsidies are expired, can you give us a sense on your M&A opportunities if that pipeline is bigger, smaller, size of the assets, and then maybe kind of touch on capital budget priorities for 2026?

I just mentioned this is Sam. We have seen some acceleration in the outpatient space, and our pipeline through acquisitions is a little greater than it's been in past years, and we continue to execute on those appropriately, assuming we can get to a reasonable deal, and we've been able to accomplish that in certain circumstances. So, from that standpoint, that's been what we've seen mostly in the market is in-market type transactions that are complementary to the network and, again, create a better patient offering for us overall. With respect to hospitals and tax-exempt hospitals specifically, you know, we just haven't seen it yet that there is a significant opportunity for for the company that makes sense from a financial standpoint. We continue to be well positioned, as you just mentioned, with our balance sheet being in a great position. The capabilities of the company as a scale player allows us to assimilate individual hospitals or hospital systems synergistically, but we haven't seen it. and so we obviously are open to those type of transactions if and when they present themselves. We're fortunate as we've mentioned in the past that we do have great markets within HCA's port and the opportunities to invest in those markets organically is compelling and we've been able to do that again in our outpatient space but also with our hospitals. Our hospitals are running 73, 74% occupancy. We have many strategic positioned hospitals that need capital. I think our capital is at an all-time high for approved projects that will come online in 26, 27, maybe early 28. It's almost $7 billion of capital that's in the pipeline. Mike alluded to the fact that we're lifting our capital spending because of those circumstances to somewhere between $5 and $5.5 billion, and we will continue to evaluate that. So we're finding ways to invest productively as well as use our assets productively with acquisitions, where appropriate, investing in our networks, and then looking for out-in-market opportunities if, in fact, they do present themselves in an appropriate way.

Your next question comes from the line of Scott Fidel with Goldman Sachs. Your line is open.

All right, thanks. Good morning. I'm curious if you could talk a bit about your expectations for growth in terms of specialties and procedures in 2026. Maybe talk about some of the areas where you're expecting outsized procedure growth around some of the categories that, you know, We've certainly seen the company investing in and then also just underlying growth due to, you know, different trends that we're seeing in the market.

This is Sam. You know, we've said this in the past, and, you know, we have geography that's diversified in a sense that no one division in HCA generates more than 10% of the profits of the company. We also have similar diversification, if you will, in services in that no specific service line generates any more than 15% of the revenue of the company. So given that, we haven't seen anything that's disproportionate vis-à-vis one other service line. I will tell you that we've seen reasonable demand for cardiac services. Some of that's technology-driven in electrophysiology. We continue to believe that that pattern will persist into 2026. Obviously, within our emergency room, we continue to believe that our emergency room services are a very important component to community health and at the same time to our networks. And so we're investing in our emergency rooms, both from a patient care standpoint, an operational throughput standpoint, as well as a supply standpoint, to make sure we have sufficient resources in that particular area. And then within surgeries, I mean, we do have specific efforts afoot, but they're more generic, if you will. They're not necessarily specialty-oriented. I will tell you that our case mix continues to grow, And that growth is driven, we believe, by the acuity of the patients in many instances in our medical space. So we see a lot of patients who have intense medical needs creating more acute care requirements, whether it's intensive care or deeper med-surg capabilities. And that's part of what is going on in the communities that we serve as well. So that's a bit of an overview. I don't have any other specifics for 2026 around growth that we expect, but we can try to get that to you if that's something that would be helpful.

Your next question comes from the line of Raj Kumar with Stevens. Your line is open.

Maybe just to enlighten the kind of recent winter storm, maybe any operational disruptions to call out and maybe kind of any considerations for the 1Q relative to annual guidance that we should be kind of thinking about related to any potential impacts there?

Like Armageddon out here in Nashville right now. So to say that we're aware of what the impacts are gonna be at this point, we're not. I mean, we've had snowstorms before. We had a massive storm in Texas a few years ago, and we were able to navigate through that. My sense is as we close out January, we'll have some sense of the impact of the storm here in Nashville, as well as a few other markets for the company. But I don't think it's as significant in most other markets as we maybe are experiencing here. Having said that, we have plenty of opportunity, I think, to recover some of the challenges that, you know, are typical for these type of storms.

Your next question comes from the line of Steve Baxter with Wells Fargo. Your line is open.

Yeah. Thank you. Could you expand a little bit on the PAWS Texas Medicaid Supplemental Payment that was mentioned during the guidance color? I guess what exactly is happening there and what needs to happen for that payment to come back online in 2026 and how much I guess of the year-over-year impact is that driving? Thank you.

So, the PAWS program is called atletology by linking interoperative systems. There was a commissioner that issued a termination notice on that program on their way out as they were leaving office. The new executive commissioner that is now in place has agreed to review that program, effectively putting it on pause versus terminating it. We don't know yet the timeline for this review, but we are encouraged that the department is willing to review the program and consider it. A closing standpoint, you know, when I think about the overall guidance for 26, and we piloted a 250 to 450 million dollar decline in net benefit from state supplemental payments. This Texas, the other two that we noted that are the other two-thirds of that decline, one would be the retro payment from Virginia that we were 25, and then second is the Tennessee program where we had a six-quarters of benefit in 25 and only four that's the their each of those three items about a third of that decline of 250 to four your next question comes from the line of Josh Raskin with nephron research

the line is open thanks so good morning I know this came up a little bit but can you speak to your technology agenda and where you think the greatest opportunities are for HTA and specifically interested in areas where you think AI can help already, looking at both the administrative costs, but also as well as the revenue enhancement opportunities?

We are investing, as Mike said, heavily in our tech agenda, and it's got multiple components We're investing in our health record transition from one system to another, and we're accelerating into that platform. That's a very important foundational piece for our company in that we're going to be able to standardize data sets across all of our hospitals. Here to four, our hospitals had a variable data set that created some challenges for us when we were using the big data. Big data for us, we believe, is the next scalable asset inside of HCA to produce better performance broadly. So, we've organized ourselves into three domains, and we are in each of the domains. The first domain is administrative, and you alluded to that. That is an area that's focused on revenue cycle, human resources, IT, supply chain in many instances, and a few other areas that we think we can accelerate into because we're more consolidated in our operations. And so we're implementing, as we speak, in our revenue cycle, in supply chain and other areas, to move through some transitions into artificial intelligence, supporting better functioning, more efficiencies, better interaction with payers and vendors and so forth. And we should start to see some value, and that's part of what Mike alluded to again again in our resiliency agenda in 2026. The second domain for us is what we're calling operational, and that's where we're delegating operational responsibilities to each of our hospitals and facilities. Here again, we have areas of focus that we think are going to create incremental value for the company and allow us to be better at throughput, asset productivity, scheduling and staffing our hospitals, scheduling and running our ORs, and so forth, and so, again, a lot of good ideas and a lot of tools that we think AI can bring to the operations of our hospital, allowing us to be a little bit more standardized, allowing us to be a little bit more consistent in performance, and then giving our management teams greater tools to run their business even better than they do today, and they run it incredibly well is what we've called the Holy Grail. And the Holy Grail for us is really centered around clinical and what we can do to support our doctors with insights that come from the patterns that we know exist in the services that we offer because of our volume. With HGA's proprietary database, that we have a wonderful opportunity to use those patterns to help our physicians in the moment make better decisions, more informed decisions potentially for their patients in a way that will improve care. The second thing on the clinical side is nursing. The opportunity to support our nurses with tools that make it easier for them to do shift change, to have a safety net underneath their day-to-day activities so they can make the patient environment safer and more efficient is in front of us. And, again, we have some solutions that we're implementing this year. Our leadership challenge and our leadership responsibility is to help our facilities manage this change, get to the other side of it so that we can create value for our patients, value for our facilities, and ultimately value for the organization. We are all in on the possibilities with artificial intelligence. merging with what I call the human intelligence that exists within our facilities. And if we can put that together in an appropriate way, and we think we can, we see a lot of value potential across quality, efficiency, and just management effectiveness.

Great. Thank you.

Your next question comes from the line of Jason Casorla with Guggenheim. Your line is open.

Great. Thanks. Good morning, and thanks for taking my question. Maybe asking the payer mix questions in a little bit of a different way. I know you've talked with the exchange enrollment kind of transitioning into uninsured, but can you give us a sense in terms of what 2026 guidance assumes for overall bad debt and uncompensated care and how that compares to 2025 levels? And perhaps if there's offsets at the external level in terms of state uncompensated care pools or programs that you could tap into as offsets there?

Well, yeah, I would say that our assumptions and our guidance certainly include this movement for the people who lose the exchange coverage, you know, the ones who don't go to employee-sponsored insurance. And, you know, for the, if you just think about kind of that component when uninsured, we do anticipate, you know, we'll see an increase in the amount of people who are entering our facilities companies with no insurance, and that is part of the math that I walked through earlier. As you know, when someone without insurance kind of immediately transitions in, the other components that we're studying are complications of when they do have insurance. And so, within the exchanges, you know, I think the potential impact here is when someone goes from so much significant, there could be a bit more.

Your last question will come from Kevin Fishbeck with Bank of America. Your line is open.

Great, thanks. Maybe just one clarification on that last point. So what is the collection rate on like a bronze versus a silver, just so that we can think about it? But then I guess more importantly, you know, you guys have been over 20% margin last year, this year, even though you've got these headwinds coming in. We kind of think about 20% margin as kind of the high end for you guys, but you're outcompeting that even with pressure. So how do you think about what kind of margin HCA can point to? You tend to be bullish about cost savings going forward. Should we be thinking about something north of 20% that is a sustainable margin for HCA?

Well, let's start with 26%. I mean, I think given the headwinds from the exchanges and exceptional payments and the fact that, you know, we've been able to develop and implement a resiliency program that has allowed us to, we're really pleased with the guidance on ground margin, which, you know, we've been able to get pretty consistent. That obviously reflects a ton of hard work in our resiliency plan, our ability to drive operating leverage through our volume growth, and our overall cost. It's a little premature to talk about what could happen in the future other than to just point you back to my comments, Kevin, where we noted that given the demand in our marketplaces, our resiliency programs, and the digital transformation that Sam just talked about, that we are comfortable that we will be able to maintain a long-term plan over time. And so, you know, I think that's a good sense of the confidence we have in the company in our performance. So, I think we'll end there.

Thank you, Colby, for your help today, and thanks to everyone for joining us on the call. We hope you have a good earnings season. We're around this afternoon if we can answer any additional questions.

This concludes today's conference call. You may now disconnect.