Q3 2023 HCA Healthcare Inc Earnings Call

Participants

Frank George Morgan; VP of IR; HCA Healthcare, Inc.

Samuel N. Hazen; CEO & Director; HCA Healthcare, Inc.

William B. Rutherford; Executive VP & CFO; HCA Healthcare, Inc.

Albert J. William Rice; Analyst; UBS Investment Bank, Research Division

Ann Kathleen Hynes; MD of Americas Research ; Mizuho Securities USA LLC, Research Division

Benjamin Hendrix; Assistant VP; RBC Capital Markets, Research Division

Benjamin Whitman Mayo; MD of Equity Research & Senior Research Analyst; Leerink Partners LLC, Research Division

Brian Gil Tanquilut; Senior Equity/Stock Analyst; Jefferies LLC, Research Division

Calvin Alexander Sternick; Analyst; JPMorgan Chase & Co, Research Division

Gary Paul Taylor; MD & Senior Equity Research Analyst; TD Cowen, Research Division

Jamie Aaron Perse; Associate; Goldman Sachs Group, Inc., Research Division

Jason Paul Cassorla; Research Analyst; Citigroup Inc., Research Division

John Wilson Ransom; MD of Equity Research & Director of Healthcare Research; Raymond James & Associates, Inc., Research Division

Joshua Richard Raskin; Research Analyst; Nephron Research LLC

Justin Lake; MD & Senior Healthcare Services Analyst; Wolfe Research, LLC

Kevin Mark Fischbeck; MD in Equity Research; BofA Securities, Research Division

Philip Chickering; Research Analyst; Deutsche Bank AG, Research Division

Sarah Elizabeth James; Research Analyst; Cantor Fitzgerald & Co., Research Division

Scott J. Fidel; MD & Analyst; Stephens Inc., Research Division

Stephen C. Baxter; Senior Equity Analyst; Wells Fargo Securities, LLC, Research Division

Presentation

Operator

Welcome to the HCA Healthcare Third Quarter 2023 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.

Frank George Morgan

Good morning, and welcome to everyone on today's call. With me this morning is our CEO, Sam Hazen; and CFO, Bill Rutherford. Sam and Bill 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 are 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 filings. On this morning's call, we will make -- 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 HCA 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 today. With that, I'll now turn the call over to Sam.

Samuel N. Hazen

All right. Good morning. Thank you for joining the call. The business fundamentals for the company were solid in the quarter with broad-based volume growth on a same facility basis across our footprint and various service lines. These results reflected continued strong demand for our services and healthy operating margins on a same-facility basis. Across most areas of our business, we maintain the operational momentum that we experienced over the past 3 quarters, including continued progress with our labor agenda. Unfortunately, our results were unfavorably impacted by our Valesco hospital-based physician venture. Bill will give additional detail on this impact in a moment.
We are continuing our efforts to integrate this venture and anticipate implementing additional actions that should improve its operational results over the next few quarters, including less pressure for the company in the fourth quarter. Because of this issue, primarily, we have lowered the top side of our earnings guidance for the year to reflect the effects of these losses.
It is important to understand that we believe the decision to consolidate Valesco was strategically imperative in maintaining the overall competitive positioning and capacity offerings of the company. As has been the case historically with our teams, I am confident that we will find a pathway forward to mitigate the impact it has had on our results.
For the third quarter, diluted earnings per share were $3.91. Same-facility admissions grew 3.4% year-over-year. Inpatient volumes were supported by continued strong acuity and a favorable payer mix with same-facility commercial admissions growing an impressive 7%. Same facility equivalent admissions increased 4.1%. This growth was driven by emergency room visits, which grew 3.5%. We are encouraged by our ER revitalization program and the results it is producing for our patients.
Outpatient surgeries on a same facility basis grew approximately 1% year-over-year. Other outpatient categories also grew, including outpatient cardiology procedures which increased almost 5%. These factors contributed to an increase in same facility revenue of 7.9% as compared to the prior year.
In the quarter, we continued to invest significantly in our people with additional investments in orientation programs, Galen College of Nursing and clinical education facilities. Turnover was stable in the quarter and nurse hiring was the strongest it has been all year.
These positive results helped reduce contract labor costs, 12.5% as compared to the third quarter last year and 11% sequentially. During the quarter, we maintained available bed capacity, instances where we could not accept patients from other hospitals representing only 0.9% of total admissions, which is consistent with the rate in the second quarter.
We believe the significant investments we are making in our networks, our people and our technology agenda will provide us with the necessary resources to improve our service offerings and deliver higher quality care to our patients with greater accessibility.
I'm proud of our people for what they do every day to deliver on our purpose. I want to thank them for their dedication and their overall great work. HCA Healthcare has a disciplined operating culture that we will maintain into the future. This focused approach, which benefits all stakeholders enhances our ability to execute clinically strategically and financially.
So let me close with this. We look forward to our upcoming Investor Day on November 9 and when we will provide more details about the company's approach to driving sustained long-term growth and shareholder value. We will also provide some early perspectives on the upcoming year as well as longer-term thinking on growth targets. With that, I will turn the call to Bill for more details on the quarter's results.

William B. Rutherford

Great. Thank you, Sam, and good morning, everyone. I will provide some additional comments on our performance for the quarter. Consolidated net revenue increased 8.3% to $16.21 billion from $14.97 billion in the prior year period. This was driven by 4.5% growth in equivalent admissions and 3.6% increase in revenue per equivalent admission.
Same-facility revenues grew 7.9%. As Sam mentioned in his comments, the Valesco joint venture had a negative impact of approximately $100 million on the company's adjusted EBITDA in the quarter as well on a year-to-date basis. A portion of the third quarter results was due to revising our revenue estimates from the second quarter as we began to see claims being paid.
This result was not what we are expecting as we are experiencing revenue shortfalls compared to what we originally modeled. The Valesco operating results had a negative impact on adjusted EBITDA margins of approximately 80 basis points in the quarter and 40 basis points on a year-to-date basis. Going forward, we anticipate the loss from this venture to approximate $50 million a quarter.
We are working diligently on multiple efforts to address these results, including making program adjustments where necessary, deploying efforts to reduce the cost structure and working with payers for more appropriate reimbursement. As we have discussed previously, we have seen subsidy requests increase from contracted hospital-based providers.
Professional fee expense for contracted providers has grown approximately 20% on a year-to-date basis. Although we are encouraged, the rate of growth of these payments slowed in the third quarter as compared to the second quarter. In addition to the mitigation strategies discussed above, we continue to assess other operational adjustments with our cost resiliency programs to help offset some of the impact from these issues.
Let me speak to some cash flow and capital allocation metrics. Our cash flow from operations was $2.48 billion in the quarter. Capital spending was $1.15 billion. We paid about $160 million of dividends and repurchased $1.14 billion of our stock during the quarter. Our debt-to-adjusted EBITDA leverage ratio remains near the low end of our stated range of 3 to 4x.
As noted in our release this morning, we are updating our full year 2023 guidance as follows: we expect revenues to range between $63.5 billion and $64.5 billion, we expect net income attributable to HCA Healthcare to range between $4.94 billion and $5.13 billion, we expect adjusted EBITDA to range between $12.3 billion and $12.6 billion and diluted earnings per share to range between $17.80 and $18.50. We expect capital spending to approximately $4.7 billion for the year.
Before we open it up for questions, I'd like to provide some commentary on our year-to-date performance. We believe our core business metrics remained solid. Year-to-date, our same facility admissions have grown 3.3%. Equivalent admissions have grown 5.1%. Non-COVID admissions have grown 7.5% over prior year on a year-to-date basis.
Same facility ER visits have grown 5.7%. Inpatient surgeries have grown 2.3% and outpatient surgeries are up 3.1%, all on a year-to-date basis. These volume metrics have outpaced our original expectations going into the year. Our payer mix trends remain favorable. Same facility managed care admissions increasing 5.3% and Medicare admissions increasing 4.3% on a year-to-date basis.
Medicaid and uninsured admissions are slightly down from the prior year on a year-to-date basis. Our case mix index has held and increased slightly over prior year and our same-facility revenues have increased 6.4% on a year-to-date basis.
Our same facility labor cost and supply costs are below prior year as a percentage of revenue. Through a focused and diligent effort, our operating teams have done an incredible job of addressing the contract labor pressures we had last year. On a year-to-date basis, our contract labor expense is down 18% or over $300 million from the prior year.
We have confidence that a similar focused and diligent effort will help address the current physician cost pressures over time. Lastly, when we look at our current adjusted EBITDA guidance for 2023, we think there are several notable items to consider. We discussed in our year-end call in January, COVID support payments, the out-of-period Texas waiver payment and the 340B impact from 2022, which all totaled approximately $500 million.
And when you consider the $145 million payer settlement we recorded in the first quarter of this year, as we take all of that into account, we are pleased with the growth rate we've been able to achieve. In addition, our diluted earnings per share, excluding losses on sale of facilities and losses on retirement of debt has grown 7.2% year-to-date. So I wanted to take a moment to put this quarter in some perspective. So with that, we look forward to your questions, and I'll turn the call over to Frank to open it up.

Frank George Morgan

Thank you, Bill. (Operator Instructions) Rianna, you may now give instructions to those who would like to ask a question.

Question and Answer Session

Operator

(Operator Instructions) Our first question comes from Kevin Fischbeck with Bank of America.

Kevin Mark Fischbeck

Great. Maybe I just want to build on that last point there. The commentary about the year-to-date performance being strong is well taken. But I guess I get a lot of questions about whether there's anything unusual, I guess, in the performance this year. I think people are trying to figure out whether this is a good base to think about future growth or whether there's anything -- whether it's in the volumes or the rate or the payer mix that we really shouldn't be expecting to continue. So I guess, is this a good base and should we think about normal growth off of this?

Samuel N. Hazen

Kevin, this is Sam. It's our belief that demand for health care remains strong and will remain strong into the future. And just given the population trends that we see in our market, the aging of the baby boomers as well as chronic conditions. And though there's been a lot of concern about GLP-1 and so forth, we think it's way too early for any of that to have an impact on demand in the near term or even the intermediate term. And so from that standpoint, we're really encouraged by what we see from a demand standpoint.
Our overall competitive positioning, we believe, continues to be strong. It's indicated within our market share trends, vis-a-vis, where we were pre-pandemic. And so we're encouraged by that. We continue to have resources, we believe, to continue investing in our company appropriately in positioning our agenda with the necessary resources to accomplish our objectives.
And so from our standpoint, economies remain strong across our portfolio and we believe that supports some of the payer mix trends that we've seen. So we're reasonably optimistic here that the overall top line metrics that you're seeing have durability.

Operator

Our next question comes from A.J. Rice with UBS.

Albert J. William Rice

Obviously, as you went through strong results, obviously, the focus on this professional fee challenge. I know coming out of the second quarter, you were -- I think -- thinking it would step down in Q3 and Q4. And now it sounds like, if anything, it probably stepped up a little bit.
I'm trying to understand what was the variance in the quarter relative to previous expectations. Was it $50 million? It sounds like even in the quarter, there's some catch-up from Q2. So maybe it's a significantly bigger number as a negative. And then is it right way to think about Q4 and into next year, a $50 million quarterly run rate that you're assuming just continues. And therefore, you've got to pick up in '24 one more $50 million adverse comparison. Hopefully, that makes sense. And if I could squeeze in just thinking about this quarter, the DPP payment from Florida. Was that in line with what you thought? Or was that -- the net benefit a little better?

William B. Rutherford

Yes. A.J., this is Bill. Let me try to take those. So let's talk about Valesco first and isolate that from a pro fees. I would tell you, our professional fee expense and on Valesco is coming in kind of what we expected. I mean, as I said, our rate of growth in the third quarter slowed from the rate of growth from the second quarter. although we continue to see subsidiary requests, and we've got efforts to mitigate those.
There's no doubt the issue for us in the quarter was the Valesco operations, as I mentioned. We're not clearing as much revenue than we anticipated. And I think it's best you have to look at that on a year-to-date basis because we did make some revisions as we started to see claims being paid in the third quarter. And we believe, as I mentioned, it's probably about a $50 million a quarter run rate for Valesco.
We have a number of efforts underway to mitigate this that I spoke of as well. But in the short run, that's what we're sizing it out. And you're right, when you look at next year, we'll have 3 quarters of it this year versus 4 next year. But we'll give you more of our thinking when we talk about '24 later on, but you sized it about right.

Albert J. William Rice

Anything on the Florida?

Samuel N. Hazen

The Florida DPP was slightly above what we expected, but we had other programs, A.J., that were less than we expected. So you got to look at it in the overall context of the revenue mix of the company. And I don't think it's that discrete necessarily to just focus on one element of it. So -- but it was slightly above.

Operator

Our next question comes from Ben Hendrix with RBC Capital Markets.

Benjamin Hendrix

Excluding Florida DPP from both quarters, EBITDA margin appears to have declined by about 180 basis year-over-year, suggesting close to $300 million total headwind. If Valesco is $100 million of that, how would you characterize the remaining $200 million or so that brings us short of the 3Q '22 margin. You mentioned the higher subsidy requests and maybe DPP in other quarters -- or in other regions other than Florida. But is there anything else to call out there that would weigh on margin?

William B. Rutherford

Yes, Ben, this is Bill. Isolate the margin really that other operating line is where you see we've lost some margin on the as reported quarter. Valesco was about 50 basis points of that when you adjust for Valesco, kind of the pro fee growth was about 40 basis points. And the balance was really due to the -- the increase of the supplemental expenses that we recorded in the quarter relative to Florida DPP and other programs.
So the way I think about it, if you exclude Valesco, other operating was off about 120 basis points, 40 to 50 was the pro fee effect and the balance was just the increase in the supplemental expenses that we recognized in the quarter. Labor was strong and I talked about is supply positive trend. So it's really isolated to those 2 issues, the Valesco supplemental payments as much as anything.

Samuel N. Hazen

I think, Bill, just to add a point to that. Our same facility operating margins, which did include those elements Bill spoke to, we're actually in line with our internal expectations. So I think from the standpoint of a little bit of pressure, we anticipated some pressure, but it was reflected again in the overall performance of our same facility. So the most of this lands on the Valesco challenge with respect to the revenue and the earnings associated with that venture.

Operator

Our next question is from Gary Taylor with TD Cowen.

Gary Paul Taylor

One question and one clarification. Just on the clarification, I think we'll see this in the Q, but I think professional fees were 22% of other OpEx in the 1Q, 24% in the 2Q. Just wondering what that number was for the third quarter. It sounds like it maybe slowed a little bit or didn't change a lot.
And then my real question just really was about hitting into '24. I mean, we see a lot of volume strength. I mean if we look at the stack comps year-to-year admissions, adjusted admissions, ER, all accelerated pretty nicely. I'm just wondering how you're thinking about carrying that volume strength into '24 and presumably, the guidance you'll give us in a few weeks at Investor Day.

Samuel N. Hazen

Well, Gary, this is Sam and Bill can jump in here. We believe, again, that our core business, our hospital-centric core business is performing well. I mean our volumes were broad-based. Every division in our company had admission growth had adjusted admission growth, every service category in our business offerings had growth, except for OV, our obstetrics volume. Mainly births were down slightly. Pediatric was down slightly, and our behavior was down because we made capacity adjustments, but not because demand is shrinking in behavioral just because we needed capacity that we felt might be more productive. So across geography and across service lines, really solid performance.
On the labor front, we were investing in the quarter in our labor agenda at the same time as making improvements. And what I mean by that, we have invested heavily in new graduate training programs. We've done that throughout the year. That actually created a little bit of a headwind in the quarter and throughout the year for us. We think that will help us as we push into the fourth quarter and on into '24 with making adjustments to our labor agenda. We've invested in our Galen College of Nursing facilities as well as our other clinical education. So we're investing in our agenda for the long-term prospects that all of these initiatives represent.
Bill spoke to the revenue yield. I think the revenue yield from acuity, payer mix and pricing is positive. So I mentioned that our same-store results were in line with our expectation. I think the second thing that's important here, Gary, is that we pride ourselves on making adjustments if we have a variance. And I am confident in our teams. I'm confident in who we are as an organization. And we've proven it over time that we can make adjustments and find solutions to really complex problems.
And so we've got one. It's not what we anticipated. But again, we had the necessary requirements to consolidate a business that was struggling and somewhat distressed but very important to our offerings in the community. So I think as we work through it, as we gain a better understanding of it, we will be able to make adjustments and get the proper reimbursement we need from the payers for the services that we're now providing.
And so fortunately, our balance sheet remains strong, as Bill alluded to, and our ability to invest in our agenda to maintain our positioning and execute on our agenda remains strong. So when I pull up and provide some context here, I'm encouraged by what I see in the quarter and for the year and what that portends for the company as we push into the future.

William B. Rutherford

And Gary, this is Bill on your clarification. Pro fees as a percent of other operating was just under 24% in Q3, similar to what it was in Q2.

Operator

Our next question comes from Ann Hynes with Mizuho.

Ann Kathleen Hynes

I know you don't want to provide 2024 guidance now, but is there any major headwinds and tailwinds that you want to call out before heading into the event? And to that degree, I know Nevada is introducing the UPL program. Do you have any sense on what that incremental benefit will be next year?

William B. Rutherford

Ann, this is Bill. Yes, there's -- Only one we'll call out, as I mentioned in my comments, is the payer settlement we recorded in the first quarter other than that, we'll give you our full commentary later on 2024. And on Nevada, it's still too early. We're waiting for the approval level. And when we discuss '24, we'll update you on what our thinking is, and that -- any estimate of that is.

Operator

Our next question comes from Whit Mayo with Leerink Partners.

Benjamin Whitman Mayo

Sam, can you maybe just go back and elaborate on the ER revitalization program, how Valesco plays into that? And exactly where you are in the evolution of that program and any tangible progress that you expect to see in 2024?

Samuel N. Hazen

So our ER revitalization program was initiated maybe a year ago, 9 months ago with -- I don't remember the exact point. We determined that -- a couple of things; one, demand for emergency room services continues to be robust. It was actually more resilient coming out of the pandemic than we had anticipated. So we felt we needed to reenergize our operations because we have had some turnover in our leadership, and we had the business opportunity associated with demand. So our teams came together and went about sort of revitalizing for lack of a better term, our basic operations with respect to our emergency rooms.
We have proven standards and processes over time that we think create a really good experience and a positive outcome for our patients. And so we wanted to retrain a number of our new leaders, including some of our physician leaders through Valesco and others into these standards in these processes. And the early results of our program are really positive. Our patient satisfaction is up 4 or 5 points from when we began the program.
Our throughput continues to improve. I think we're seeing an ER patient within 9 or 10 minutes with a clinician. As soon as they present to our door, our throughput times with respect to discharging our patients has improved as well as those who get admitted, we're able to get them on to the floors more efficiently than we were before.
We continue to believe we have opportunities to strengthen that program. And so we're expanding the reach of our training. Again, that will include our physician leadership, both in Valesco as well as other hospital provider contractors that we have. And we think this will play in well into our investments that we're making into our emergency room platform, both hospital-based as well as our freestanding emergency rooms, which continue to perform at an even higher level.
So all of that to say is it's yielded volume growth, it's yielded patient throughput improvement. And most importantly, it's yielded patient satisfaction increases that we are encouraged by. We will continue to hopefully achieve.

Operator

Our next question comes from Brian Tanquilut with Jefferies.

Brian Gil Tanquilut

Sam, it seems like you have an idea of what needs to be done in Valesco. But maybe going down to the nuts and bolts of it. As we think about the fact that you employ these docs now, it sounds like there's more of a revenue issue. So is that just a matter of tacking them on to the HCA contract? Or what needs to be done there? And maybe just for Bill, kind of related to this, if you can give us the contribution of Valesco to revenue per same-store admit.

Samuel N. Hazen

Let me speak to how we're approaching it. Again, we're learning as we go. I forgot -- I think it was like 5,000 physicians across, how many, 200 different programs. A really large-scale business that, again, we felt we were at a point where we had to make a decision, and I'm comfortable that we made the right decision for the company long term. So as we learn more and more about this business, we think there are going to be opportunities on how we allocate the staffing underneath this business.
Obviously, our emergency rooms are 24/7, 365, won't necessarily change the staffing per se, but there could be complementary approaches to that. There are overhead opportunities. We think, over time, we will be able to get to. But you're right. Ultimately, we will need to get paid for these services appropriately. We do have some contracts today. We feel like those will have to be adjusted in the future. And we're confident that we can achieve appropriate reimbursement underneath these programs and get us to where it's an appropriate service that's reimbursed reasonably as we get through it.
But that's just not happening immediately. And that's part of the challenge. And again, we need anesthesiologists. We need emergency room physicians. We need hospitals in order to deliver the volume and maintain positioning. And so that rationale into our decision-making. And so now we have to rationalize the operations, and I think those are the areas that we're going to focus on. And we believe in a reasonable period of time, we'll make progress on that.

William B. Rutherford

Brian, to your revenue numbers, Valesco revenue is just under $400 million year-to-date, about $380 million on a year-to-date basis.

Operator

Our next question comes from Stephen Baxter with Wells Fargo.

Stephen C. Baxter

I appreciate all the commentary on the professional fees and the growth slowing in the third quarter. So it does still seem like a pretty challenging environment out there for those firms. And as we do some checks here, and anesthesia in particular remains a pressure point. Is this something that you think you can manage closer to flat going forward? Or is it just becoming part of the new norm around something that you'll need to offset as you think about the puts and takes for 2024?

William B. Rutherford

Well, it's hard to call. We do believe the rate of growth should slow going forward compared to what we've seen this year. As I said, we're working diligently on multiple work efforts not only in Valesco but working with our contracted providers as well. So again, I think we'll see a slowing growth. We we've dealt with some of the more acute issues out there. But the subsequent question is still there, but we're managing through it, and we'll continue to do that as we continue to go on. We'll update you on our progress, but we're working diligently to effect and slow that rate of growth and its impact on us.

Samuel N. Hazen

I think Bill alluded to this in his commentary earlier about the pressures we saw with contract labor, nurse shortages, capacity management [before]. And I would submit that we've worked our way through that reasonably well. And we still believe there are opportunities for us to make strides forward on that agenda.
We're going to learn from that how we managed that at timely aggressively and responsibly and I think apply those same learnings to the situation we have here and get to an answer that makes sense for the company. And so I'm confident, as I said, that we have the mindset and the wherewithal to work through these and get us to a reasonable solution.

Operator

Our next question comes from Pito Chickering with Deutsche Bank.

Philip Chickering

There are a lot of moving parts to the margin this quarter. But if you normalize for the Florida DPP and the $50 million from prior period in Valesco, and look at the implied fourth quarter margin ramp it looks higher than normal sequential margin improvement from the fourth quarter. So can you help bridge us sort of what are the key drivers to get to that implied guidance for margins for 4Q?

William B. Rutherford

Yes. Historically, our fourth quarter is our best margin performance quarter. Obviously, this quarter was impacted a little higher than normal because of the Valesco 80 basis points I talked about and the Florida DPP. Our same facility margins were over 20%. So we think our guidance is reasonable based on our outlook right now. But I think it's a combination of maybe not having some of the -- the immediate pressures we had this quarter and the expectation that the fourth quarter tends to trend stronger than our average.

Operator

Our next question comes from Cal Sternick with JPMorgan.

Calvin Alexander Sternick

Just wanted to go back to Valesco for a second. So is the expectation that the $50 million loss per quarter persist this level throughout next year? Or would you expect to end the year at a slightly lower run rate? And then just on the mitigation levers, I mean, obviously, it sounds like reimbursement is probably the bigger component here. But is there any way to give a sense for magnitude of the cost side. I'm just wondering if you could give some color on what those levers are and just how much of that $50 million you think could offset purely just with cost reductions.

William B. Rutherford

Yes. I mean, so right now, as I said, probably $50 million a quarter, but we're working diligently to mitigate that. And as we go through the next couple of quarters and into '24, we'll continue to update on our progress on that. We view the primary issue as revenue shortfalls, and that's what we're working through. There may be some cost adjustments we can make, but I think it's primarily a revenue approach that we're going to take to try to turn the results around.
And I just have to -- but it's $50 million a quarter, and we have confidence that we've dealt with several issues in the past and we'll work through that. It's primarily a revenue challenge that we'll get through. And didn't mention earlier, but with our increased position, we now manage the revenue cycle all the way through. So I think that puts us in a much better position to assess and address some of these revenue trends. So we have the revenue cycle function from contracting to coding to billing and collections. And so we think we're in a reasonably good position to be able to at least assess those trends and then come up with appropriate actions to respond to them.

Operator

Our next question comes from Jason Cassorla with Citigroup.

Jason Paul Cassorla

Great. I guess with surgery is up about 1% in the quarter, a little bit better on the inpatient side. I wanted to ask about trends within service lines. And the comp was a little bit difficult this quarter. But anything to call out there? And then Sam, it sounds like from your comments, you're not seeing any impact on GLP-1, so you don't expect much there, but just making sure we caught that right. And if you have any other thoughts on potential impacts, underlying demand or trends in the line would be helpful.

Samuel N. Hazen

Yes. Let me start with the GLP issue. We think it's way too early to make any judgment about the effects on our business generally. I think the second point that I would make related to GLP-1 is the fact that we have a very diversified mix of revenue as a company. I mean, obviously, we've gone through orthopedic total joints going from inpatient to outpatient. We've seen other drugs come into the mix, statin as an example with cardiology and we're actually doing more cardiology procedures in the company now that we've ever done in the history of the company. So I don't really know how to judge the implications.
Bariatric surgeries in our company is a really small program, less than 0.5% of overall revenue. Obviously, we have patients who do have diabetes, but some of those patients aren't going to lose it necessarily immediately either. So it's way too early to make judgments, we believe, around that. When you look at the mix of business, again, as I said earlier, we had very broad-based service line performance that was solid. Very few service categories were down. We actually had a calendar headwind and in the quarter with respect to surgical days and cardiology procedure days where we had 1 less surgical day in the quarter than we did last year. So our performance in the face of that headwind was strong as well.
So that's what I would say it was similar on the inpatient and outpatient as far as the mix of service volume growth and so forth. So very consistent, very broad-based, again, across our geography. And so we're pretty pleased with the outputs.

Operator

Our next question comes from Scott Fidel with Stephens.

Scott J. Fidel

I was hoping you could maybe talk about some of these recent developments in the environment as it relates to the potential indicators around future wage trends and in particularly thinking about some of the union actions that we've been seeing in some of these minimum wage laws that are getting passed at the state level, such as in California. Just curious on sort of whether you see these in aggregate potentially creating some more pro inflationary pressure on wages? Or do you think that there may be a bit over sort of focused on and won't affect the overall trajectory of the wage environment?

Samuel N. Hazen

The market for labor has normalized in very material ways compared to where it was 1 year or 1.5 years ago. And we're seeing it in our cost per hour as a company, which has really lined up with the expectations we had for the year, and we've seen stabilization across the elements of our compensation programs and so forth.
There are some minimum wage laws out in California that has a very de minimis impact on our company. Most of our compensation was already in line with that have very few issues with that. Unionization across the country beyond the health care industry is an issue as everybody understands but we have been successful in pushing through those issues organizationally and have landed in a spot that we think is not going to put too much pressure on our business in the near term.
And so that's where we are. Obviously, the markets change. They're dynamic, and we have to adjust to those but we're seeing positive signs with respect to turnover with respect to hiring and even the number of new students who are populating our Galen College of Nursing programs is very encouraging, suggesting that there's a sufficient pipeline of new nurses who want to be educated and go into the workforce.
So we're pretty encouraged by the macros that we're seeing. There are obviously issues that we have to pay attention to, and we are but we're reasonably encouraged with our overall agenda as it relates to our people and the efforts that we have in place.

Operator

Our next question comes from Jamie Perse with Goldman Sachs.

Jamie Aaron Perse

Just a bigger picture question for you guys. You've talked about longer-term margins, 19% to 20% being a fairly sustainable range for you. A lot of moving parts right now. So just at a high level, is there anything you see in the business right now that can take you off of that trajectory more permanently and just your level of confidence in getting back to that margin rate and sustaining it going forward?

William B. Rutherford

Yes. I mean, this is Bill. I think we have a reasonably long track record of producing margins that are in a pretty tight range. Even as we've dealt with periodic cost pressures, whether it be contract labor before or maybe bad debts in the previous cycle and or physician costs now. So I think as a team, we have confidence we can continue to operate the company at reasonably strong efficiency levels.
We've spoken in the past. We have a number of initiatives around technology and innovation on resiliency programs that continue to target the opportunities to operate even more efficiently in the future. So I think our historical performance is a reasonable expectation for us and we've got opportunity to continue to drive efficiencies through the organization.

Operator

Our next question comes from John Ransom with Raymond James.

John Wilson Ransom

If I take your $380 million of Valesco, I think you did a little over $220 million in 2Q. So that means the revenue dropped sequentially by like $60 million. I know you're talking about this a revenue problem, but in your guidance going forward, maybe you could clarify kind of your revenue and cost outlook to get you to that minus 50. And again, why was it such a -- I know seasonality is a lot -- such as steep ramp in 3Q or decline in 3Q on revenue unless the number wrong.

William B. Rutherford

John alluded to this in my comments, we did make some revisions to our revenue estimates in the third quarter. In the second quarter, it's still new. We were putting providers on new contracts still, we have not received a lot of claims being paid as -- claims started to be adjudicated and paid. So I think it's better to just look at that on a year-to-date basis on there. It's roughly $200 million a quarter, somewhere around that neighborhood is kind of what we think the model will be going forward, again, may fall on either side of that. But I think it's best to look at the year-to-date. We understand the third quarter, John, but it's really just because we had no history on there and as claims started to be paid, we were able to revise that. So that's why it's $100 million EBITDA for year -- for the quarter, it's about the same year-to-date. It kind of ties into our $50 million going forward.

John Wilson Ransom

So it's $200 million revenue, $250 million cost business is what's embedded in your guide going forward, just to be clear.

William B. Rutherford

Yes. If you want to think very broadly, that would be pretty consistent.

Operator

Our next question comes from Justin Lake with Wolfe Research.

Justin Lake

I'm going to pile on with this physician stuff. So just -- I've never seen a business kind of be off this far from, like you guys are obviously very, very good at what you do. I know this is a new business, but to be $50 million of revenue on a $200 million -- let's say, $250 million baseline, 20%. So just the -- like can you triple click on that for me and just say like what did you think was going on versus what is? And then the -- for -- when you gave your headwinds, tailwinds for next year, the only headwind you talked about with that payment, which makes sense. But you've given some numbers around the subsidy costs, right, the physician costs that run through other operating. And they do seem like they've been a pretty big drag on margins. My estimate is somewhere around $300 million, give or take, year-over-year versus kind of revenue growth.
Are you assuming that that's not going to grow at anywhere close to that pace next year? Or do you think you could like -- and therefore, it's not another $300 million headwind next year? Or are you just assuming that we can offset it? And so we kind of grow normally ex the $145 million?

William B. Rutherford

All right, Justin. Well, a couple of things. One, [never] really talk about '24. We'll give you our '24 guidance assumptions some of that on the Investor Day in more detail as we go through the planning on there. But as I said, we are expecting to pro fee growth rate trends to lower going forward. And we're working diligently to make that happen.
On your opening question around Valesco just to emphasize what Sam said, this was a very complex and large integration of 200 programs, 5,000 providers that happen very quickly. And we were operating maybe on some incomplete historical data. And as we started to see claims being paid, the revenue is just clearing at lower rates than we anticipated. And again, I think we've got a number of initiatives to try to offset that. And so we're working on both of those.
But -- so that's how I would address the Valesco shortfall right now. And then we're continuing to work on the pro fee and we do expect that growth rate to decline going forward.

Operator

Our next question comes from Sarah James with Cantor Fitzgerald.

Sarah Elizabeth James

So when I look at the moving pieces in the guidance revision and the change in the Valesco revenue. It looks like you guys are implying core is doing a little bit better, especially if I use midpoint. So can you give us an update on what you're seeing so far in the first couple of months into 4Q volumes and how we should think about what 2023 guidance implies for the volume transition from 3Q to 4Q?

William B. Rutherford

Yes. So as you know, we don't comment on the current quarter. We've made, I think, several comments on the core business trends we're seeing with really strong volume, reasonable pricing, the core operating expenses of the company are doing well in labor and supplies. I think as a broad brush, it would be our expectation, those trends generally continue going forward. We don't see anything from a macro perspective changing that.
But again, too early, we're not commenting on kind of intra-quarter or early quarter activities. But as I said and Sam mentioned in his comments, we're pleased with the core fundamentals that we're seeing. Good demand in the market. We're positioned very well and our same facility operations is going pretty well. Unfortunately, we are dealing with the Valesco integrations and we'll overcome that. But I think you can reasonably expect that our core trends that we've seen year-to-date should, for the most part, continue at a reasonable pace.

Operator

Our next question comes from Joshua Raskin with Nephron Research.

Joshua Richard Raskin

Hate to beat this dead horse. But just on the reduction in revenues on Valesco as the claims were getting processed. I'm just curious what was causing that reduction in revenue? Was that a lower rate issue? Was that payer mix? Was that reduction in codes submitted versus paid? Or was that just less services? And then I know there's been some challenges there no surprise at underway that the arbitration process just started back up again. Is any event going to mitigate any of the impact there?

William B. Rutherford

Yes, Jeff. So it's hard to attribute the shortfall in any one area. As I said, we were operating on maybe some incomplete historical data as our model is and probably an array of other issues that potential other hospital providers are experiencing. And so yes, we've got a number of initiatives that we're going to try to address that we've talked about. We can continue to see -- we prefer to be an in-network providers to avoid the out of the surprise billing and that IDR process. And so we're working with our payers diligently to be in network and to get reasonable rates going forward, and that's going to be part of our action plan.

Operator

Our next question comes from Brian Tanquilut with Jefferies.

Frank George Morgan

Rianna, I think we're done. If you want to close the queue.

Operator

Thank you. Seeing no further questions, I will now turn the call back over to Frank Morgan for closing remarks.

Frank George Morgan

Rianna, thank you so much for your help today, and thanks to everyone for joining on the call. I'm around this afternoon, if I can answer any additional questions you might have. Have a great day.

Operator

This concludes today's conference call. Thank you for your participation. You may now disconnect.