Welcome to the HCA Healthcare Fourth Quarter 2019 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, Mark Kimbrough. Please go ahead, sir.

Kevin, thank you so much. Good morning, and welcome to everybody on the call today and our webcast. With me this morning is our CEO, Sam Hazen; and Bill Rutherford, our CFO, which will provide comments on the company's results for the fourth quarter. Before I turn the call over to Sam, let me remind everybody that should today's call contain any forward-looking statements that are based on management's current expectations, numerous risks, uncertainties and other factors may cause actual results to differ materially from those that may 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 may reference measures such as adjusted EBITDA and net income attributable to HCA Healthcare, Inc., excluding gains and losses on facilities, which are non-GAAP financial measures. A table providing supplemental information on adjusted EBITDA and reconciling to net income attributable to HCA Healthcare, Inc. to adjusted EBITDA is included in today's fourth quarter earnings release. This morning's call is being recorded, and a replay of the call will be available later today. I will now turn the call over to Sam.

All right. Thank you, Mark. Good morning, and thank you for joining us today. We finished the year with strong fourth quarter results that were above our expectations. Solid volume increases, strong revenue growth and good expense management drove this quarter's results. Revenue increased on a year-over-year basis by 10% to $13.5 billion. This increase was driven again this quarter by a combination of strong same-facilities volume growth and our recent acquisitions. On a same-facilities basis, revenue increased by 6%, which was driven by 4.7% growth in inpatient admissions and 5% growth in equivalent admissions. We saw growth across most service categories and broadly across most markets in the company. To highlight a few additional service categories, emergency room visits grew 6.7%, and total surgeries grew around 2% with roughly equal growth in both the inpatient and outpatient settings. We have now grown inpatient admissions in 23 consecutive quarters. This remarkable consistency reflects positive market forces across our diversified portfolio, a robust growth agenda, significant capital spending and strong execution by our people. The growth in revenue translated into strong earnings for the quarter with diluted earnings per share of $3.09. Adjusted EBITDA grew 9.2% to over $2.7 billion with adjusted EBITDA margin at 20.3%. 2019 was another successful year for HCA Healthcare. The company's results, which improved across most key performance metrics, reflected both the steadfast commitment we have to our mission and our disciplined operational culture. Across our networks, we took care of more than 35 million patients in 2019, a record level of patient volumes. We spent $4.1 billion in capital expenditures. About 1/2 were for routine needs, and the balance were investments needed to support our growth agenda. The strategic investments we made in our business to expand our network and improve our clinical capabilities made…

Great. Thank you, Sam, and good morning, everyone. I will cover some additional information relating to the fourth quarter results and then briefly discuss our 2020 guidance. As Sam mentioned, all of our stats for the quarter were solid. We were pleased with the quarter and full year results, so let me provide you with some additional information. During the fourth quarter, same-facility Medicare admissions increased 4.3%, and equivalent admissions increased 5%. This includes both traditional and Managed Medicare. Same facility Medicaid admissions increased 5.1%, and equivalent admissions increased 4.6% in the fourth quarter compared to the prior year. Our same-facility managed care admissions increased 4.7%, and equivalent admissions increased 4.8% in the fourth quarter compared to the prior year. Our same-facility self-pay and charity admissions increased 6.8%, and equivalent admissions increased 6.5% in the fourth quarter compared to the prior year. Same-facility emergency room visits increased 6.7% in the quarter. Our level 1 through 3 visits increased 8%, while our higher-acuity level 4 and 5 visits increased 5.3% over the prior year. In addition, admissions through the emergency room increased 4.7% over the prior year. Same facility net revenue per equivalent admission grew 1.1% over the prior year in the quarter. Our net revenue per equivalent admission growth in the fourth quarter of 2018 of 4.4% was one of the strongest we have seen since 2014. Also, our acuity growth was lower than trend due to our medical admission growth of 5.9%, which outpaced our surgical admission growth of about 2%. For full year 2019, our same-facility net revenue per equivalent admission has grown 2.3%, which is in line with our guidance range for the year. Our same-facility inpatient net revenue grew 6.5% in the quarter, and our same-facility outpatient net revenue grew 5.8% in the quarter. So let…

All right. Thank you, Bill. Kevin, you can now provide instructions for those on the call who wish to ask questions.

[Operator Instructions]. We will take our first question from Pito Chickering of Deutsche Bank.

A question for you on CapEx. CapEx as a percent of revenue guidance looks to be about 7.5% in 2020 versus 8.1% in 2019. As you think about CapEx over the next two, three years, do you think CapEx continues to drift down? And are you able to facilitate the same level of EBITDA growth? Or asked differently, what is the balance between CapEx spend versus EBITDA growth?

Thanks, Pito. So yes. When we look at capital, keeping a relatively flat in our guidance for 2020, we look at it as a percentage of our cash flow from operations. And with the strength of the cash flow, I think this current level of $4 billion to $4.2 billion is a good planning estimate for us. We continue to see opportunities to deploy capital to facilitate our growth, either through capacity expansion or network development or deepen program capability. So I think as long as we continue to see the growth of our cash flow, good capital opportunities, nice growth of our returns on invested capital that we think it's an important component of our ability to generate future growth.

Yes. Let me add to that, Bill. It's Sam, Pito. I think in 2019, we had some early-stage capital investments that we knew we're going to have to make with our Mission acquisition and our Savannah acquisition, and that tended to be earlier in our model. And so there was some acceleration in those items, and that lifted up our CapExes a little bit as a percent of revenue, and that's why it's dialed back. As Bill said, we continue to believe we have opportunities in our existing markets organically to deploy capital and deal with growth opportunity, competitive positioning and even capacity constraints. In the face of all of these new beds that we've added over the years, our occupancy levels continue to go up. And so that's really encouraging that our planning and the execution underneath it is occurring at the levels that we had hoped. And so that's where we are at this particular point with our capital.

We will now go to Frank Morgan of RBC Capital Markets.

A question about the guidance. When you think about the high end of that range, clearly higher than it has been in the past, are there any particular things that you could call out that may be the primary driver to getting the high end of that growth? And I guess specifically, what are you factoring in for the reentry into the network in Las Vegas? And then what about the DSH cuts that I think have been postponed through May of '20? Where do you have that in the -- how do you have that factored into guidance for the year?

Yes, Frank. This is Bill. Let me take that and talk about our guidance overall. As you know, if you look at the midpoint of our guidance, it's about 6% growth rate. At the high point, it's at 8%. And that's before reflecting any adjustment for the payer settlement we had in 2019, which add roughly about 1% of those growth rates. I think that's consistent with our commentary that we had in the third quarter that we continue to see momentum in the marketplace, and that is allowing us to perform from the core operations at the top end of our long-term guidance, and we think acquisitions will continue to contribute growth for us. We estimate about 1%, a little bit north of 1% for acquisitions. So when we look at in totality, the range accounts for a number of those variables. We continue to see volume opportunities as we see demand and market share capabilities. And I think that 6% to 8% on an as-reported basis, probably 7% to 9% when you adjust for the payer settlement is a good planning range for us.

And then, Frank, with respect -- this is Sam. With respect to the Las Vegas situation with Sierra, we do see that particular contract being a material change in our strategic dynamics in that market, but the magnitude of it for the company as a whole is not material. And Las Vegas is part of a diversified portfolio inside of HCA and is a very significant market for us and is doing incredibly well without the Sierra contract, and we have significant investments going into the market that are dealing with the population growth that's occurring in that market as well as now access to more lives. So we're very excited about it. We think it's reflective of the strategic partnerships that we have with our payers and trying to figure out ways to deliver value to them, and we're excited about the prospects of being in the Sierra relationship in Las Vegas.

And then, Frank, on your DSH cuts, we look at that in the context of our overall Medicare rate increase. As we've talked about before, we think we're in a favorable Medicare rate update, 2.5% to 3%. We are not forecasting any material Medicaid DSH cuts at this point in time, so we'll just have to wait to see how that dialogue continues going forward.

Our next question comes from Kevin Fischbeck of Bank of America.

I wanted to follow up on the pricing commentary from earlier. It sounded like you were saying that most of it, in your view, was just kind of from a mix perspective. Could you talk a little bit about what you're seeing on the commercial side? Obviously, that numbers are moving around a lot. So how did that impact pricing, what pricing you're getting in commercial? And then, two, did flu have any impact either on the volume or the pricing in the quarter?

Kevin, this is Sam. I think we're in a really good position with our contracting strategies with the commercial payer marketplace. And as we just mentioned, we've gained access to Sierra in Las Vegas which opens up more commercial lives for us as a system. But in general, we're roughly 85% contracted for 2020 and almost 2/3 contracted for 2021 and about 1/3 contracted for 2022 in generally consistent terms across our portfolio. As it relates to the revenue per unit in the quarter, our commercial revenue per unit was reflective of sort of the overall trend. It was underneath maybe our composite. And that was due, we think, to the lower medical book that Bill alluded to and also some outpatient growth in certain areas which starts to mess with the number a little bit. But nonetheless, our commercial book is doing about what we thought, and we saw great growth in high-end services with neonatal services, with trauma services, orthopedic services, cardiovascular. So our approach to delivering high-quality, complex services is yielding value. It was offset a little bit. That's why we had a little bit more volume in the quarter because of the medical growth that we saw in the fourth quarter, and that creates a net effect of the numbers we report. That also affects our cost, as Bill alluded to. And that's why we were able to create, on a per-unit basis, margin expansion, in addition to sort of the overall growth.

Our next question comes from A.J. Rice of Crédit Suisse.

Let me just maybe focus in on your -- if your debt to EBITDA is down at 3.4, that's sort of toward the low end of -- or even maybe slightly below the low end of your, I think, 3.5 to 4.5 target. If I think about the different buckets of where you can deploy capital, you're raising the dividend. You've re-upped the buyback, but it's been pretty steady in the $1 billion to $1.5 billion annual range. You've got -- you've been doing some tuck-ins and then a few larger deals, and then there's been steady capital deployment, but I don't know whether some of these deals or what's your comment on Vegas or something opens up new opportunities. So I guess I'm leading up to asking, can you go through each of those buckets and say where the priorities are? Has there been any evolution on any of that in terms of maybe tuck-in deals with the prospects for doing bigger deals or whatever? Give us some update on that.

Sure.

Yes. A.J., this is Bill. Let me start and Sam can add on. So you're right. Our leverage ratio at 3.42% is the lowest we've run since before the LBO. We're fortunate we did finish the year stronger than originally anticipated. We continue to look at that long-term range and give a lot of thought, too. I think ultimately gives the company an incredible amount of flexibility, and we continue to assess all 3 areas that you talk about. First is to continue to evaluate strategic acquisitions. We do expect a couple of smaller acquisitions that are in the pipeline to be completed. We did complete the acquisition of Galen School of Nursing in January. And as you mentioned and we've mentioned before, we are usually evaluating a couple of larger acquisition opportunities at any particular time. It's hard to call exactly when and if they might be completed, but we have the balance sheet capacity to execute on these, if they come to fruition. And also, as you mentioned, second, we continue to evaluate capital investment opportunities that will provide growth. We've talked about that earlier, either through expand capacity, expand our network, improve our competitive positioning. Interesting, in 2019, we brought on over 1,000 new inpatient beds. And as Sam mentioned, we're running one of the highest occupancies we've run in quite some time. So we continue to see capital investment opportunities in the market. And then, third, as we mentioned in the release, we do have a new $2 billion share repurchase authorization. That's on top of the $1.2 billion remaining on our 2019 authorization. And although the program has no specific time limit, there are a lot of factors that influences our timing and pacing on this and the quarterly dividend. So I think when I step back, we've got a pretty long track record of a balanced and I think disciplined capital purchase. As we continue to see acquisition opportunities, we have the capability to do that. As we see capital investment opportunities and then manage the balance sheet through the share repurchase program is all part of our capital strategy.

Our next question comes from Scott Fidel of Stephens.

My question is just on, obviously, I know you don't give quarterly guidance. But just thinking about the seasonality of EBITDA margins in 2020 and just anything maybe that you'd want to call out, if necessary, as it relates to sort of workday mix and then just also with sort of the progression of the margin realization on some of the acquisitions last year or for 2019. Just in general, how we should think about sort of year-over-year comps for margins on a quarterly basis over the course of the year.

Thanks, Scott. This is Bill. Two things on that. You're right. We don't give quarterly guidance, but we'll make a quick note. And remember that our first quarter of 2019 was an extremely strong quarter for us, not only from operational performance, but we did record the payer settlement in the first quarter. So that's the only note I would tell you -- I would say. Outside of that, our quarterly spread is probably consistent with our recent trends. We are pleased with the acquisitions and their continued progression, and we saw that throughout 2019. Relative to margins, we talked about before, on a full year basis, they were running high teens, but we saw those improve throughout the year. In the fourth quarter, they were hovering just above 10%. So we expect those margins to continue to evolve in 2020. And then other than that, I would say the net -- our normal progression would be what our trends have been.

Just a clarification. I think you said high teens. I think you meant high single digits.

High single digits, yes. I'm sorry on that.

Our next question comes from Ralph Giacobbe of Citi.

The volume stack obviously popped out. Can you give us a little more in terms of what you attribute the strength to, both sort of on, I guess, a macro level and then specific to your initiatives in markets? And I want to go back to sort of your prepared remarks and commentary around better competitive positioning, hoping you could flesh that out a little bit. Is that just related to sort of your access strategies? Or is that more a reflection of the competitiveness in your market where some of the -- some of your peers maybe are struggling a little more? Just some help on that.

Thank you, Ralph. Sam, you want to start?

Yes. I think the first point I would make is we believe and we've said this and we continue to believe it and we're seeing evidence even in 2019 that there's growing demand for health care services in HCA's markets. And we're very protective of our portfolio for a reason, and part of that is due to the fact that we're trying to pick markets that we believe have macro trends that are supportive of a growth agenda. So that's number one. When you look at -- the second point I would suggest is that we have a model that we believe is very competitive and responsive to the marketplace and responds to those growth opportunities, responds to competitive dynamics and really responds to our stakeholders: our patients, our physicians and our employees and really the community, so four key stakeholders. And the first point is really about building out broader and more clinically capable networks. We've talked about we want our networks to be conveniently located, easy for the patient to access and navigate, have different price points and then fundamentally our one-stop shops as a system with comprehensive service lines, so our patients can obtain all their health care inside of HCA network. So we've added 2 facility offerings. This past year, we added with an acquisition of an urgent care center, we added with a couple of acquisitions of ambulatory surgery centers, and then we developed a number of outpatient facilities, including freestanding emergency rooms, urgent care centers, physician clinics and so forth. So we now have more than 2,000 sites of care that are connected to our 185 hospitals. They work as a system. We still have opportunities to have them work more effectively as a system and create better value for the patient, better value…

Our next question comes from Whit Mayo of UBS.

Maybe I'll just follow up, Sam, on your comments there about your physician strategy. Is there anything changing with your hospital coverage or your outsourcing strategy? I mean you talk a lot about the evolving physician strategy, but has anything changed as you kind of marry your physician needs with your capital strategy this year as I sort of hear you talk about high-cost complex, service development, trauma, et cetera? Does that just maybe influence how you think about anesthesiology or anything along those lines?

Whit, this is Sam again. On hospital-based physicians, we have a multifaceted approach to hospital-based physicians. In critical care medicine, as an example, in our intensive care units, and this has been a part of our efficiencies that we've talked about in the past, we have, I think, the largest intensive critical care medicine group in the country. They are deployed across a number of our facilities. We're able to leverage their learnings, some of our data to support better critical care management. We're trying to figure out how to use that platform for advancing telemedicine and critical care to support rural hospitals and to support some of our other facilities. That's one example. The second thing would be on pathology. We have a very large pathology group that provide pathology services across HCA, not in every facility, but a number of facilities and growing. With respect to emergency room and anesthesia and hospitals, we have a mixed solution there. We contract largely with outside organizations, national organizations, in many instances, in some local organizations. We do have some employment models there as well. We'll continue to evaluate whether or not it makes sense for us to contract or to employ. We have the wherewithal to do both. And we work with our contracted providers very effectively to deliver high-quality, efficient care and respond to the marketplace. So that model is evolving a little bit, as you know. And as it evolves, we will adjust appropriately. But hospital-based physicians are a key part of our physician strategy. They're very important to patient care. They're very important to patient satisfaction. They're very important to the efficiencies that we have. And so we have strategic relationships, again, locally, at a national level and then through our employee model. And we will continue to sort that out as the years progress.

Our next question comes from Steve Tanal of Goldman Sachs.

I guess I had two quick ones. One was on the recently acquired hospitals. The last, around the Medicare cost reports, I think, put the EBITDA margins on a 4-wall basis around 6-or-so percent. Sounds like you're saying high singles, maybe not too different. So first, just wondering where you think that could go over time. And then more about the quarter. I was hoping to just get a little bit of clarity around the flu, the impact that you guys would estimate on admissions, revenue per adjusted admission and EBITDA and maybe tying those comments into revenue per adjusted admission with a comment on the acuity index where that shook out for the quarter and maybe even same-store revenue per adjusted admission for the commercial book. I know you've provided that in the past, just to help us think about that number there.

All right. Steve, thanks. Steve, let me try to cover some of those. First on the acquisitions. As I mentioned earlier, at least attempted to, the acquisitions for the full year were running at the high single-digit margin level. We saw those improved throughout the year and hover just over 10% in the fourth quarter. We think, over time, we can get those to a reasonable margin level. This would be basically in the mid-teen range. I think all of the acquisitions we've talked about before will take up as a multiyear prong for us. So over time, we think we can continue to see margin improvement there. On the flu. The flu was mostly an outpatient impact for us during the quarter. With our emergency room business, we think probably 150, 170 basis points growth in that emergency room visit volume that we reported, the 6.7%. Very little effect on our inpatient admissions for the quarter. Our best estimate in the quarter is relatively nominal impact on the flu on our inpatient admissions. And I don't think it has much impact at all, if we look at the other kind of financial statistics, both either on a revenue, revenue per unit or an earnings standpoint. More a volume standpoint as we saw activity in our emergency rooms.

Our next question comes from Steve Valiquette of Barclays.

This is Andrew Mok on for Steve. During January, you've finalized your acquisition of the Galan College of Nursing. Can you speak to the strategic benefit from a partnership like that in terms of building a pipeline of nursing labor to feed into your hospitals? Is that an area where we should continue to expect additional investments? And secondly, can you give us an update on the labor and wage trends you're seeing in your end markets, including what's embedded in your 2020 outlook?

Galan School of Nursing here.

Okay. Well, first of all, we're very excited about the acquisition of the Galan School of Nursing. They have a tremendous leadership in Mark Vogt, number one. Number two, their culture aligns with HCA's culture in a very significant way. So that was part of the appeal. The second thing that we learned when we studied that organization is they have a scalable model. And when you connect that scalable model with the unique platform of HCA, we think we can create a nursing school education program that starts to scale up across most of our major markets. So we're in the final stages of building a multiyear plan to expand Galen School of Nursing and integrate that component of education with a robust agenda we have for clinical education and nursing support for our existing nurses, hopefully creating both a pipeline and a continuous education cycle inside of HCA so that our nurses are more capable of delivering high-quality care but also have more opportunities for growth. And we think that's a winning formula for us. So the investment requirements to do that are modest. They're not significant. It's really about getting the right faculty, the right administrative leadership and so forth, and the team is working on that as we speak. But we're very excited about what the education opportunities for the Galen School of Nursing can do for HCA. And again, that parallels what we're doing with graduate medical education today for physicians inside of HCA. Both of these components, we think, provide a tremendous community benefit for our communities in that we're creating a supply of caregivers to deal with some challenges that exist on a macro level in many markets. As it relates to labor costs, in general, we're anticipating 2020 to be consistent with what we've seen over the past few years. I think HCA has been able to respond to market dynamics very effectively with our wage and compensation programs. We've recently enhanced our living wage policy program as an organization to respond to certain dynamics on that front. And then with respect to nursing, we've been able to respond to market dynamics effectively and keep our wage trends within a level that we think are consistent with where we have guided number one but responsive to what's going on in the market. So we fully anticipate a continuation of past trends in our model for 2020.

Our next question comes from Josh Raskin of Nephron Research.

I wanted to ask sort of again on the leverage and just push a little bit. You guys are below your long-term targets at sort of 3.4. And if I kind of just run out share buybacks at current levels, good dividend that you've talked about, the share repurchase -- I'm sorry, the CapEx guidance that you've given. And I know acquisitions are lumpy and difficult to time, et cetera, but you'll be closer to 3 than 3.5 by the end of the year. So is there a point where there's sort of pressure to deploy more capital? And I guess,is there an opportunity maybe for an accelerated buyback or a special dividend, things that you guys have thought about in the past for 2020?

Josh, thanks. Yes, this is Bill. Let me try to talk about that. I think we're very fortunate to have the ratio where it is. Ultimately, it gives the company, I think, a lot of flexibility into the future. I think that acquisitions, if they materialize, could affect that. We think the increase in the share repurchase program we're anticipating for 2020, we will continue to evaluate that. I don't think it puts any pressure towards your question to us. It just gives us opportunity, I think, to continue the growth trajectory of HCA, either through acquisitions or capital and share repurchase program. I think it will likely be a combination of all 3 of those as it has been in the past going forward.

Our next question comes from Michael Newshel of Evercore ISI.

I just want to get your latest view on the price transparency regulation finalized by CMS, how it might influence payer negotiations and also market share. And are there like interesting like practical technology challenges be ready for 2021 there? Or do you think the core challenges are just going to likely delay this?

This is Sam. The pricing transparency, as we've said in the past, is a policy that we're supportive of as it relates to protecting the patient. And so we believe that any transparency policy that supports the patient getting information when they can in advance of their care on their co-pay deductibles and so forth is something that we can support. As it relates to our commercial pricing contract, we're not supportive of that. We don't think it necessarily will accomplish what others are saying it will accomplish, number one. Then number two, we think it is very complicated for a patient to discern and would not necessarily accomplish the patient objectives that we think are really the intentions of many people's desire here. And then finally, it will be administratively difficult and complicated, and a lot of systems won't have the capability to put those pricing arrangements forward. So that is a factor. We don't know exactly how this is going to shake out. There are a couple of approaches that the federal government has pursued, and we'll just have to wait and see how it develops. I don't anticipate it creating any significant issue for us. With respect to contracting, we think it just creates, like I said, confusion with the patient more than anything else. HCA is positioned, we believe, well with our networks. We are positioned well, we believe, from a pricing standpoint across most of our markets, and we don't anticipate that being a major issue for us. It's just that it does create a lot of confusion.

Our next question comes from Justin Lake of Wolfe Research.

A couple of follow-ups for me. First, I just wanted to see if I can get a little more color on the seasonality of 2020. I know you pointed, Bill, to the tough comp in Q1, which I calculated, I think, like 13% core EBITDA growth. So obviously, a great quarter, and then clearly, a much easier comp in Q2 where the core was closer to flat. So I was hoping you might give us some additional color here on the growth for the 2 quarters, basically asking whether you see the growth in Q1 and Q2 being only slightly different than the full year directionally. Or should we think as much as maybe flat year-over-year in Q1 might be a reasonable target, just given how strong that comp was, and maybe it gets made up in Q2?

Yes. Justin, this is Bill. Without giving specific quarterly guidance because I think if I go back to my earlier comment, our historical trends would be our best guide on there. And we're always going to be subject to some quarter-to-quarter fluctuations on there. If I go back to 2019, what we said at the end of the second quarter is that our year-to-date results were more reflective of what we thought our trend was going to be. And indeed, that was the case. So in essence, I think you -- it's hard to really call 1 quarter to the other. I think over a couple of the quarters, we still think the core fundamentals will be there. And again, last year does pose a couple of difficult comps for us, both in the first quarter and then in the second quarter. So I tend -- would look at it more on a year-to-date basis than I would quarter by quarter. And I think if you can kind of normalize through that noise, I think our historical trend would be our best guide going forward.

Got it. And then, Sam, if I could just squeeze in a second one. You made -- you talked about the benefit of getting back in network with Sierra in Vegas, and I was just hoping if you can give a little more color there in terms of given how quickly do you think the -- given the physician referral patterns have been in place for a while, how quickly do you think those can change to drive volumes to HCA? And then talk to any dilution potentially because I know you guys had some better payers, better paying volumes that have shifted over to you over time, how much those might shift out and dilute some of that benefit.

Well, let me say again, Las Vegas is a very important market to HCA. We're making significant investments in a number of our facilities, and we continue to look for opportunities to invest. I think a lot of our medical staff participates in the Sierra contract. And the opportunity to sort of repatriate them, for lack of a better term, into our facilities is what we're working on. I think, generally speaking, we believe we can -- in the early part of it, 2020 period, start to repatriate some of those positions so that it's more efficient for them to take care of their full patient load inside of HCA facilities. And we're working on that as we speak. We're seeing early indications of some of that happening as we expected, but we're obviously in a very busy time in the first quarter for a lot of our facilities. So that creates some challenges, but we'll sort that out over the course of 2020 and hopefully be in the position that we anticipated. But we're excited about it, as I mentioned, when you couple the fact that United and Sierra has a very strong position in Las Vegas. Las Vegas is a growing market, and we want to be part of that growth with respect to the largest payer in that market. So we see a lot of long-term benefit here to HCA as we execute our strategy.

Our next question comes from Sarah James of Piper Sandler.

So the stronger ER trend, even if we take out the full impact, is still up about 100 basis points sequentially. How much of that is related to your investments in expanding the trauma program and share gain? And then as we think about the coronavirus playing out, can you just remind us if there was any impact on the model from SARS or MERS and whether that showed up more in ER or urgent care?

Sure. Thanks, Sarah. So our emergency room visit, Bill alluded to this, were up 6.7% with a modest impact coming from the flu. Our freestanding emergency group platform did grow significantly. It was actually above trend. It grew north of 20%. It represents maybe 12% to 14% of our overall ER traffic. But when I look underneath the ER business, we continue to grow our EMS volume. From ground ambulance, it was up 7%, which is consistent with where we've been. Our trauma programs produced 20% volume growth, which is about consistent where we were for the year. We continue to add comprehensive stroke capabilities to our portfolio of offerings that is yielding more traffic for us in our emergency room. But what's important, I think, along the lines of program development, is patient satisfaction. We have seen our operational processing improve throughout the year. We see roughly 9 million-plus emergency room visits a year. On average, we see a patient with a clinician within 11 minutes. Our time to discharge has dropped in 2019 as compared to 2018, and that's yielding both capacity, number one. But more importantly, it's yielding better patient satisfaction. And we think the combination of all of that is driving better performance, better growth and allowing us to use the investments that we put forth in this particular service category more effectively.

What about SARS in emergency room?

SARS?

Yes. Impact on emergency room.

Jon Perlin, our Chief Medical Officer.

Good morning. Historically, SARS or MERS, which are members of the coronavirus family but far more toxic than the current novel coronavirus, did not affect our emergency department volumes.

Our next question comes from Gary Taylor of JPMorgan.

Two-part question. The first was I don't think we got the same-store all-payer CMIs this quarter and last. Was wondering if we could get those. And the second part was we've heard some from some hospitals about a cardinal recall of some sterile gowns and surgical kits and causing a little bit of disruption in the ORs in January. Wondering if you're seeing that. And if so, do you think you can just backfill whatever that disruption is in the next few weeks or months, such that the quarterly impact is probably immaterial?

All right. I'll let Jon take that last one, and then we'll circle back on CMI.

Dr. Jon Perlin here. No. We're fortunate that there are other vendors of the surgical slides you've referenced. Entire supply chain has a pipeline on those have not disrupted our operations.

Yes. Gary, on case mix. I think, as we alluded throughout a couple of comments during the call, we did see a lower trend on our case mix growth in the quarter, principally due to that growth of medical admission outpatient and the surgical admission growth.

Our next question comes from Brian Tanquilut of Jefferies.

Congrats on a good quarter. Sam, I guess just my question would be on total joint replacement or total knees with CMS approving reimbursement at the beginning of the year. How do you think that changes your strategy on joint replacement? And should we be expecting some volume shifting from inpatient to outpatient over the next few quarters or few years?

Let me start with this. Number one, in the quarter, I think total joints for HCA went up 7%. That's pretty consistent with where they were in the first 3 quarters of the year. Roughly 15% of our total joints are done on an outpatient basis, some in our hospitals, some in our ambulatory surgery centers. Obviously, with the new reimbursement protocols, we anticipate a few more transitioning to that setting. Our goal is to have a comprehensive orthopedic service line. So that means we're trying to align with the physicians in a way that create the environment that they want, the environment they need for their patients, the most efficient environment for the payers. And so we are always dealing with migration patterns as technology advances, and that's part of our run rate. We don't anticipate anything happening in 2020 that's going to materially change our trend as a result of one service category having a bit of migration from one setting to the other. We talk a lot about the diversified portfolio of markets. I think it's equally important to talk about the diversified portfolio of services in HCA. Orthopedics is a very important service line, but it's one of many. It represents less than 10% of our overall revenue. And so if there's a bit of migration and pattern changes inside of that, it doesn't really offset the larger revenue picture for the company. But we're excited about some of the technology that's advanced in orthopedics. We're excited about the research opportunities that we have with our physicians, and we're excited about further alignment of physician groups across the company as it relates to what we're trying to do with orthopedics as a whole. We've had success similarly in cardiovascular care, where we've been able to use service line capabilities and very specialized talent to support different initiatives. We're doing the same in orthopedics, and we think it's going to yield value for the company in the future as we continue to align with high-quality groups.

Our next question comes from Peter Costa of Wells Fargo Securities.

Looking at your acquisitions, I think you said about 1% of your EBITDA growth is coming from the acquisitions. Is that all of the acquisitions: Asheville, Houston, Savannah and New Hampshire? Were any of those not -- no longer improving faster than your core operations? And then if I'm doing the math right, your core operations look like they're improving sort of 6% to 8%. If we take the 7% to 9% and then back off the 1% for the acquisitions, it seems like your EBITDA growth from your core operations is growing at a faster rate than your long-term guidance. And I just want to make sure you want to stay with your same long-term guidance of 4% to 6%.

All right. Yes, Peter, this is Bill. Let me start. Yes. The acquisitions for 2020 will be about 1%, a little bit north. And that is for our '17, '18 and '19 acquisitions going forward on there. As we look at the numbers, we see the core hovering around that 6% and then the acquisitions being that additional 1% to drive us in that -- a little bit north of our longer-term range. And again, I think that is consistent with the discussion we had at the end of the third quarter. And it does not yet include any projection for acquisitions that have yet to be completed. And at this point, we don't see change in kind of that long-term guidance going forward.

I think it's important, this is Sam, to understand that we don't stop pushing on any opportunity. If we have an opportunity in the marketplace today, I mean, we're going to push through it as aggressively as we possibly can. So I think that's part of the operating culture of this company is to optimize the situation, whatever it may be. And I mean we understand the challenge that's out there with our guidance, and we're working through a period of time where we've had a better growth than maybe we've indicated. But I don't think that necessarily puts us in a position yet to change the long-term guidance. As we get through 2020, if we continue to see patterns that are favorable, we will make sure we inform you all appropriately on our thinking around those patterns.

Our next question comes from Matthew Gillmor of Baird.

I wanted to ask about commercial volumes more specifically. Obviously, a very strong quarter, I think one of the strongest quarters we can recall. I was curious if there was any service line or geography you'd call out for the quarter? And then how are you thinking about the commercial volume trend into 2020?

This is Sam. I think what we said is we feel like, number one, our portfolio of markets have a lot of positive macro factors that are delivering job growth, more people in commercially insured products. And that's -- we're seeing that in demand. In the second quarter of 2019, which is the latest quarter we have for market share data, the commercial demand across HCA's markets grew by about 1.3%. We think we're picking up market share on commercial business as a result of our network -- investments in program strategies and physician strategies and such. And that's part of the success. We are obviously excited, as I mentioned, about the Las Vegas scenario, and we have other efforts underway to align with payers. So the commercial side, for us, as we look forward, we anticipate demand in that area of maybe 1% to 1.25%; overall demand on the inpatient side, maybe 1.5% to 2%, as we've mentioned in the past. And we believe, again, the programs, the investments, the outreach efforts that we have underway should yield market share gains, but we just need to continue to execute on those basic elements.

Our final question comes from Matthew Borsch of BMO Capital Markets.

All right. I'll try to keep it brief. I just was going to ask that -- as we look ahead, the challenge there that we might face at some point, obviously, via turn in the economy. My question is, as you look back at how you've responded to past recessions, what has sort of been the takeaway in terms of your own lessons learned? Did you responded too quickly, not quickly enough? I'm sure you have a play enough on the shelf somewhere. I'm just -- I guess I'm just asking if that's something that is in your thinking right now and something that you're planning for.

Great. Thank you, Matt. This is Sam. Let me start, and Bill can color in some things here. I think, number one, HCA has proven over time an ability as a large company to make adjustments timely. So I'm really proud of what our teams do in responding to their routine business dynamics. Obviously, if there's a macro factor where the economy starts to contract a little bit, that has implications. Historically, what we've seen is we tend to lag the economy, in general. The health care industry tends to lag. What's different about the economy -- the health care economy today versus previous recessions is the exchange and the ability for individuals who could possibly lose a job going to COBRA for a period of time and then be uninsured. Today, there's potentially a safety net in many markets where the exchanges and the subsidies connected to that or Medicaid in expanded states, and the support from the Medicaid program provide a bit of a safety net. We haven't determined exactly how to process that yet, and that could create a different resiliency, if you will, with respect to our ability to navigate a recession. But as a general rule, our teams are constantly evaluating their trends, competitors and so forth and making adjustments, but we do have that one big factor out there. That's a new dynamic that we are evaluating and trying to understand, but we don't have any experience with it.

There are no further questions at this time.

Great. Thank you. I want to thank everybody for joining us today on the call and on the webcast. I'm around in the office. Feel free to give me a call or e-mail me if you have additional questions. Thank you so much.

Ladies and gentlemen, this concludes today's conference call. Thank you for your participation. You may now disconnect.