Surgery Partners, Inc. (SGRY) Q3 2020 Earnings Report, Transcript and Summary

Greetings and welcome to the Surgery Partners' Third Quarter 2020 Earnings Call. At this time, all participants are in a listen-only mode. A question-and-answer session will follow the formal presentation. [Operator Instructions] As a reminder, this conference is being recorded. I would now like to turn the conference over to your host, Mr. Tom Cowhey, Chief Financial Officer for Surgery Partners. Thank you, you may begin.

Good morning, and welcome to Surgery Partners' Third Quarter 2020 Earnings Call. This is Tom Cowhey, Chief Financial Officer. Joining me today are Wayne DeVeydt, Surgery Partners Executive Chairman; and Eric Evans, Surgery Partners' Chief Executive Officer. As a reminder, during this call, we will make forward-looking statements. Risk factors that may impact those statements and could cause actual future results to differ materially from currently projected results are described in this morning's press release and the reports we filed with the SEC. The company does not undertake any duty to update such forward-looking statements. Additionally, during today's call, the company will discuss certain non-GAAP measures, which we believe can be useful in evaluating our performance. The presentation of this additional information should not be considered in isolation, or as a substitute for results prepared in accordance with GAAP. A reconciliation of these measures can be found in our earnings release, which is posted on our website at surgerypartners.com and in our most recent quarterly report when filed. With that, I'll turn the call over to Wayne. Wayne?

Thank you, Tom. Good morning, and thank you all for joining us today. Before we begin our call this morning, I would like to acknowledge and recognize our colleagues and physician partners that continue to support the healthcare system and the needs of our patients. These continue to be unique times and we're humbled to be affiliated with the heroes who have embodied our mission of enhancing patient quality of life through partnership. We are grateful for your service and the sacrifices that you and your families are making each and every day. As we've previously discussed, our management team has built and is executing upon a framework for growth. We continue to take a data-driven approach to decision making, focusing on high growth specialties and capitalizing on anticipated tailwinds, such as the transition of many Medicare related procedures from inpatient to outpatient. Our strategy was built to support sustainable long-term double-digit growth. Our results support our conviction in this view. The impact of the pandemic has pressure-tested our business model and management team. In the second quarter, our results prove both the flexibility and resiliency of our business model and the strength of the leadership team we've assembled. With that momentum going into the third quarter, we felt confident in our ability to execute in and capitalize on today's environment, which has accelerated some of the longer term tailwinds we've been anticipating. Our third quarter results have confirmed our optimism. Some notable highlights include the following: adjusted revenues increased to $503.9 million, nearly 10% over the prior year quarter. Our same-store adjusted revenue per case increased by nearly 12% compared to the prior year quarter, more than offsetting the slightly lower volumes as a result of the pandemic. And finally, the transition of procedures out of traditional acute care inpatient settings accelerated during the quarter. Joint replacements in our ASCs were up 115% as compared to the prior year quarter. For the year, even with the disruption of COVID, joint replacements in our ASCs have increased by almost 90%. As you can see, these uncertain times are further highlighted the value of our short-stay surgical facilities as patients, physicians and health plans recognize the relative safety of our specialized surgical environment. CMS has also been accelerating this trend by allowing more procedures to be done safely on an outpatient basis and leaving it up to the physicians to determine when inpatient care is required. These trends which are aligned with patient and physician preferences emphasize the importance of care delivery, migrating to lower-cost, high-quality, purpose-built settings like our short-stay surgical centers. Said differently, we do not believe our results reflect solely a COVID rebound, but rather, we believe there's a fundamental market shift underway and we are marshaling resources to capitalize on these accelerating trends and gain market share. Before I turn the call over to Eric, I would like to highlight one last item. We've discussed the importance of pruning non-strategic assets to eliminate distractions and to focus our investment of time and resources into our purpose-built short-stay surgical facilities. Over the past several years, we've been intentional to eliminate these distractions. In the third quarter, we took an important step removing two assets that were not core to our long-term growth strategy. Specifically, we closed our Logan lab facility and completed the sale of certain anesthesia assets to a partner that can help us to optimize these capabilities and further enhance efficiencies in our facilities. While Eric and Tom provide more details, the sales of such anesthesia assets coupled with our third quarter debt raise provide ample capital to further invest into our long term growth strategy both organically and inorganically. With that, let me turn the call over to Eric. Eric?

Thank you, Wayne, and good morning. Today, I will focus my comments on three areas; first, I will provide a few additional highlights of our results; second, I will outline some of the key initiatives and investments that have allowed us to navigate this crisis while accelerating our long-term growth trajectory; and finally, I will provide a brief update on CARES Act guidance. Tom will then share greater detail on third quarter financial results and full year outlook along with insights regarding 2021. As it relates to the quarter, the strong momentum we saw late in the second quarter continued throughout the third quarter highlighted by adjusted EBITDA growth, excluding grants of approximately 7% over the prior year, and same-facility revenue growth of 8.4%, driven by a net revenue per case increase of 11.9%. Our same-facility volumes for the quarter averaged 97% of the prior year and in the month of September, we achieved 99% of prior year volumes -- our best results since the beginning of the pandemic. We continue to see higher acuity cases such as orthopedic and spine surgeries exceeding prior year levels while the recovery of lower acuity cases such as GI continue to slightly lag with results in the low 90s percentile of prior year volume for the quarter. Our ability to continue to achieve industry-leading same-facility growth is a direct result of our investments in physician recruitment, retention, and targeted facility level and service line investments. A few examples. We continue to see an increase in demand from new positions for our short-stay surgical facilities and our targeted physician recruitment approach has focused our efforts on the highest quality physicians. Year-to-date, we have recruited over 400 new physicians representing approximately 10% new additions to our medical staff this year. And our average new physician to date is generating 21% more revenue and 25% more revenue per case as compared to the 2019 cohort. Our ability to attract higher acuity procedures is even more evident when you compare the number of physicians performing joint replacements in our facilities as compared to the prior year, which is up 62%. We continue to make prudent investments to increase our reach and engagement with prospective physicians. Notably, we have launched an impressive digital outreach capability which has been timely given the changes to our recruitment process during the pandemic. We believe this data-driven approach in digital innovation will be a differentiator to continue to accelerate our physician growth. Another example it supports our ability to recruit new physicians and retain existing positions is our willingness to expand our facilities and invest in robotics and other initiatives to improve the patient experience and to enhance our high acuity capabilities. We have consistently expanded facilities to capture new growth while maintaining a disciplined approach to capital deployment to ensure an attractive ROI. Key ASC investments include moving multiple ASCs into new locations such as Milenia facility in Orlando Florida and our Spine Center in St. Louis investing in surgical hospital expansions and capabilities by adding operating rooms at facilities in Georgia, Idaho, North Carolina, Montana and Texas, and building a state of the art 88-bed acute care hospital in Idaho Falls, which is helping to combat the COVID outbreak in that state as we speak. We have also increased our installed base of robotics by 24% in 2020 and have plans to further expand in 2021. On the patient experience side, 11 of our 15 eligible surgical hospitals earned a five-star designation in the July 2020 HCAHPS star rating as administered by CMS, with the remaining eligible hospitals all earning a four-star rating. We are extremely proud of this result and what it says about our exceptional colleagues, physicians and facilities. This level of performance means that approximately 75% of our surgical hospitals provide a patient experience that is among the top docile in the nation and all of our surgical hospitals provide care in the top third of all measured. These investments coupled with our high-quality patient experience in our facilities has enabled us to boast a 96% physician partner retention rate. Finally, we are investing in new service lines. One we are particularly excited about is cardiology. We now have three surgical hospitals and two ASCs that currently perform cardio procedures. The ASC is our early stage expansion and pilot programs which are showing promising returns while our surgical hospitals continue to mature and expand their high acuity cardiology capabilities. On a year-to-date basis, our cardio procedures are up 8% as compared to 2019. We are planning to more than double the number of ASCs that perform cardio procedures in 2021 and continue to evaluate surgical hospital expansion opportunities. In addition to our growth initiatives, we continue to mature our operating system to become a leaner, more efficient organization. Our second quarter results highlighted the highly variable nature of our cost structure and the various actions we were able to implement with agility. As you can see from our third quarter results, we continue to invest into our facilities while maintaining the spending discipline implemented in the second quarter. Specifically, our third quarter salary and benefit expense as a percent of revenue was over 230 basis points lower than the prior year period. We will continue these and other margin expansion efforts by pursuing consolidation and outsourcing opportunities, and enhancing services to our facilities and vision [ph] partners. Before I provide an update on the CARES Act guidance, one final item that I would like to address relates to our strategic efforts to expand our footprint through acquisitions. As Wayne mentioned, we have pruned additional assets from the portfolio and are using proceeds to reinvest in our facilities and to grow our platform. Specifically, we plan to continue to pursue high growth facilities that provide physicians and patients with more convenient, cost-effective options for care. To that end, we close two transactions late in the third quarter and another in early October, expanding our orthopedic and multi-specialty footprint. At the end of October, we also completed the acquisition of a majority interest in Bakersfield Heart Hospital in California, a three-operating room, four cath lab physician-owned hospital with 47 beds that specializes in cardiology and orthopedic procedures. These transactions help to replace earnings from the sale of our anesthesia assets and other portfolio optimization efforts and support our long term double-digit growth goal. As Wayne mentioned, we believe we are in a strong position to continue to take market share and expand our footprint. Tom will provide further details regarding our liquidity available for future investments. The last topic I would like to address relates to CARES Act grants. On a year-to-date basis, we have received approximately $53 million and CARES Act funds, of which we have recognized approximately $33 million as other income based on loss [ph] revenues since the COVID outbreak. As a result of updated guidance received during the quarter, we reversed $9.9 million of CARES Act grants on the income statement related to the second quarter. The remaining grant money received that has not been recognized as revenue will now be treated as a deferred liability on our balance sheet. Based on new guidance released by HHS in mid-October, we will again update the recognition methodology for these grants when we report the fourth quarter. We recognize the uncertainties that continue to exist with COVID as we enter the winter months, and appreciate the government's flexibility in allowing frontline responders to retain such funds until this crisis has subsided. If we are unable to recognize these funds in accordance with the CMS guidelines, we will repay them in mid-2021. We believe that this crisis has fundamentally changed the way patients, surgeons and health plans will think about the role that purpose built short-stay surgical facilities will play in healthcare delivery, which continues to drive the shift of surgeries to our facilities. This has been our company's differentiation strategy. And now more than ever, our value proposition is resonating with key stakeholders in the healthcare environment. We remain very confident in our long term organic growth model and believe that scaled independent operators such as surgery partners are uniquely positioned to grow in this new marketplace. With that, I will turn the call over to Tom who will provide additional color on our financial results and outlook. Tom?

Thanks, Eric. First, I'll spend a few minutes on our third quarter financial performance before moving on to liquidity and some considerations as we move into the fourth quarter and 2021. Starting with the top line, surgical cases declined by 2.6% to just under $127,000 in the quarter primarily due to a slower return of lower acuity procedures in our gastrointestinal and pain management service lines in the early months of the quarter. Adjusted revenues for the quarter were $504 million, almost 10% higher than the prior year period. Reported results included approximately $17 million of contributions from our new community hospital in Idaho Falls. On a same-facility basis, total revenue increased 8.4% in the third quarter. Looking at the components of this increase, our case volume was 3% lower than the prior year period, offset by higher net revenue per case that increased almost 12% driven by acuity mix and pricing. Turning to operating earnings. Our third quarter 2020 adjusted EBITDA excluding grants was $66.5 million, a 7% increase from the comparable period in 2019. As Eric mentioned, using the September guidance from HHS, we reversed $9.9 million in CARES Act grants during the third quarter, resulting in a $5 million decrease to adjusted EBITDA after accounting for non-controlling interest. To date under the September guidance, we have recognized approximately $33.2 million of CARES Act grants, translating to approximately $21.9 million of adjusted EBITDA impact this year. We will be updating this accrual again in the fourth quarter based on the revised October guidance from HHS. During the quarter, we recorded $7.5 million of transaction integration and acquisition costs. Of note, third quarter 2020 transaction integration and acquisition costs included approximately $2 million of EBITDA losses associated with our de novo hospital in Idaho Falls, as that facility continues to make progress towards achieving profitability. As I've noted before, we expect to report results from this facility separately throughout 2020. Moving on to cash flow and liquidity. We ended the quarter with a strong cash position of $450 million, which includes approximately $120 million of the Medicare advanced payments. We have held these advanced payments as deferred revenue in our financial statements. During the third quarter, the deadline for repaying these advances was extended by approximately 17 months to September 2022, with interest rates after the repayment deadline reduced to 4%. Recoupment of these funds from future Medicare revenue will now commence in the second quarter of 2021. As noted on the second quarter call, we raised an additional $115 million of gross proceeds by an add-on offering to our 2027 notes to focus on growth-related activities. In addition, our liquidity position is further enhanced by our undrawn revolver, which has a capacity of approximately $113 million after giving consideration to outstanding letters of credit. Of note during the third quarter, Surgery Partners had operating cash flows of approximately $27 million, raised an additional $115 million of incremental senior notes due 2027 as just discussed, completed the divestiture of selected anesthesia assets for an undisclosed price and invested in increased ownership in our surgical hospital in Post Falls for approximately $17 million, a transaction which is recorded in our financing cash flows due to our existing ownership position. The company's ratio of total net debt to EBITDA at the end of the third quarter as calculated under the company's credit agreement was stable at approximately 7x, primarily as a result of higher cash balances, offset by the pro forma impact of our anesthesia sale and lab closure. Normalizing for the impact of Medicare advanced payment funds, the ratio of total net debt to EBITDA would have been 7.4x. The company has an appropriately flexible capital structure with no financial covenants on the term loan or our senior notes. As mentioned on our prior calls, the company's lenders under its revolving credit facility waived our leverage covenant for the remainder of 2020 and provided substantial flexibility for the calculation in 2021. On August 31, as part of our strategic efforts to focus on our core business, we made the decision to close Logan Laboratories, a component of our ancillary services operating segment which was the driver of a $34 million goodwill impairment loss on our third quarter financials. Our stated strategy is to focus on our short-stay surgical business and our actions during the third quarter reflect our continued progress towards this strategic objective. Through the third quarter, our increased emphasis on expanding key service lines such as musculoskeletal and cardiology, targeting high-value physician recruits, and engaging in strategic rate negotiations have all continued to fuel our recovery and growth trajectory. While the evolution of this pandemic and to what extent the economy will improve is unknown, we have not yet seen a material shift in payer mix due to higher unemployment levels. We continue to project adjusted EBITDA in the range of $250 million to $260 million this year. This indicative range assumes that the volume levels and corresponding specialty mix, payer mix and net revenue per case metrics that we have seen in the second and third quarters persist and improve, consistent with prior years as we enter this seasonally high fourth quarter. That -- we do not see broad-based elective procedure restrictions or stay at home orders issued on our key geographies, that we can continue to make progress in our initiatives in the midst of a pandemic and that we can recognize modest incremental amounts of CARES Act grants in the fourth quarter based on the newly issued October 2020 guidance from HHS. As is typical this time of year as we focus on finishing 2020 strong, we're starting to look to 2021. At this stage, we remain optimistic that we can outrun the short-term impacts of COVID and get back on the multi-year double-digit adjusted EBITDA growth trajectory and profit levels that we had originally been targeting based on a pre-COVID baseline. As we look to 2021, we are closely evaluating the following key elements of our growth model and business. We continue to believe in the value that our facilities offer and our recruiting teams continue to make excellent progress in recruiting new doctors to drive continued volume gains. On the rate front, we continue to make progress and fixing historical inequities in driving towards fair market rates. But we're also evaluating opportunities to enhance long term value growth by making incremental investments in certain markets. Our strategic initiatives continue to bear fruit as we work to standardize and enhance our procurements and revenue cycle operations and continue to find efficiencies in our infrastructure. With respect to our portfolio optimization initiatives, short term headwinds from the closure of the lab and the sale of anesthesia should be more than offset by the transactions we have recently completed and we are focused on deploying additional capital to achieve our growth goals in 2021. And finally, we continue to remain optimistic that Idaho Falls community hospital will continue to advance towards EBITDA profitability in 2021 despite the challenges of opening a new hospital in the midst of a pandemic. While there are still many uncertainties in this new environment, we believe we have demonstrated the value of our business model by successfully navigating through the challenges of this pandemic and look forward to continuing to report our progress in 2021. With that, I'd like to call turn the call back over to the operator for questions. Operator?

Thank you. At this time, we'll be conducting a question-and-answer session. [Operator Instructions] Our first question comes from the line of Frank Morgan with RBC Capital Markets. Please proceed with your question.

Good morning. Appreciate the commentary about how the trends were during the quarter and certainly how they ended. But I'm curious if you have any early indications on, is that trend continuing into October and any maybe discussions around kind of regional variations in the recovery? And then I guess the last part of that would just be obviously talk about a recent surge. Any color around how that's impacting your markets? And that's it.

Good morning, Frank. This is Eric Evans. Appreciate the question. I would start with just looking at fourth quarter, it's obviously early, but it's been consistent with what we have laid out in our expectations when we talked about getting to a $250 million to $260 million range this year. The Q4 is continuing our trend. Clearly there are hotspots around the country and we think about those, we've dealt with those already. You'll remember earlier in the year, obviously, we have a big footprint in Florida, California, Texas, places that were impacted. We managed through that quite well. The difference then, of course was the PPE shortage, which we have addressed. So I think about our hotspots we have to deal with today, I visited many of these markets and certainly stay close to them. I think our purpose-built facilities and our ability to provide a safe haven for elective surgery positions us well to deal with them. Clearly, you can't control all the impacts, but we feel our ability to manage through those even in many states where we do face a surge is quite high. So I would say that our confidence continues in the fourth quarter, we continue our trend and we're monitoring closely COVID hotspots, but so far, we continue to manage them well.

Appreciate the color and the reiteration of the $250 million to $260 million. In terms of cash flow from ops, obviously weaker this quarter, but how should we think about our cash flow from ops plays out for the year? And just to confirm, does the $250 million to $260 million include more CARES Act in the fourth quarter? Thank you.

Hey, Frank, it's Tom. As you think about CARES Act, we took a big reversal this quarter and we're still in reiterating the guidance of $250 million to $260 million. So I want to make sure that you appreciate that. The thing that's funny about the CARES Act in the October guidance is that it isn't necessarily designed to aid growth companies. So as you think about year-to-date same-store, we're looking at about a 3% decline in same-store revenues. So depending upon how much growth we see in the fourth quarter, that may impact our ability to have substantial recognition of the CARES Act grants in the fourth quarter. So we're watching that closely. I would say our current outlook doesn't anticipate that we're going to get back as much as we've reversed.

Hey, Frank, just to add to Tom's comment about cash flow, you asked what [ph] in the quarter. It's an interesting dynamic because there's a lot of unique timing items in Q3. So for example, obviously we hunkered down as did every company in Q2, not knowing what the future would look like. And so accounts payables did slowdown, AR continues to collect, but it's collecting from Q1. As you get into Q3, you have less AR on the books coming out of Q2 and you're accelerating your accounts payable outflow as you're ramping up your businesses and getting back to as you saw 97% prior your volumes in the quarter and 99% by September. So first and foremost, I would tell you the cash flow is purely a timing issue, very pandemic-focused and related in terms of how it's impacted that. And then the last thing I would just say, as Tom said, obviously we're optimistic coming out of Q3. Our run rate was strong. As Eric said, we like our volume that we can see in October. We're still closing the books, though, so we don't have the mix yet fully locked down, but the volume looks good and our scheduling for November looks good. So I think Tom's important point he's trying to make sure people understand is if you're a growth company like we are, the rules are not going to allow you to earn as much of CARES grants as others may be able to earn. And that's okay with us because we think one, we want to be socially responsible, return what we can; and two, we think growth companies are where we want to be. We'd rather be having that run rate going into next year and feeling good about the business model.

Thank you very much.

Thank you. Our next question comes from line of Kevin Fischbeck with Bank of America. Please proceed with your question.

Good morning. Excuse me. Good morning. This is actually Joana [ph] filling in for Kevin. So thanks for taking the question here. You said -- I also want to stay on the topic, I guess on what Frank started with, also, for next year, appreciate the commentary there and could you just talk about some of the elements you were flagging? So one item I was interested in is you talk about pricing. So there are I guess, two pieces; liquidity [ph] higher this year. So how do you think that's going to cut into next year? Do you expect high acuity to stay given your service lines extensions and ambitions [ph] and also, maybe some of the credit that was deferred, when people come back, they are sicker. And then the second piece, it seems to me is also commercial -- contract repricing that you guys talked about in the past? So where you are on that process? How much more there is to go? What kind of benefit should we be looking for next year or over the next years? Thank you.

Let me start, because there's a lot of questions and then sub parts. And so let me just start with kind of a bigger picture view and then I'll tee up Tom and Eric to add any color commentary to some of this. So let me just start first and foremost, as we look in the next year, I want to remind everybody that our double-digit growth is really based on three very simple premises, kind of pillars of growth, if you will. One is we need to grow revenue by 4% to 6% on a same-store basis. We continue to believe because of our physician recruitment and our managed care that we can outrun that 4% to 6%, be at the high end and actually perform better than that. And we think our results continue to prove that to be true, including this quarter in a pandemic environment. And I'll let Eric comment in a minute on our recruiting efforts and how our most recent recruiting class looks and how that will evolve. The second component we talked about is we generally want to get 3% to 5% improvement through efficiencies across the business -- a combination of procurement, RCM and really just being a leaner organization. And I will tell you, having sat through yesterday's board meeting, my confidence in that is just as high as it's been the last couple years, that the team continues to execute, they have line of sight on everything they're pursuing and I feel good. And then the third component is M&A. And as you know, we hit the pause button on that for a while especially when we got to COVID. It was really important. We didn't understand how long this would last. That being said, we were able to execute and eliminate distractions in the quarter, were able to quickly redeploy that capital. As you heard Tom talk about headwinds and tailwinds. The headwinds of the EBITDA, the things we divested or closed have now been already fully offset by the recent transactions we completed in late Q3 and the ones we just completed in Q4. So any capital we deploy from this point forward -- and I'll let Tom talk about in a moment about what we could have available for deployment over the next year -- so in theory helps us towards that double-digit growth. With that, I'd like Eric, just to comment very briefly on the physician recruiting and some of the recent trends then I'm going to ask Tom to talk about capital that we think we could deploy in the next 12 months.

Thanks, Wayne. So just to your question, I think I'll start with acuity and this goes through recruiting. You asked whether we think acuity is going to stay high next year and we absolutely do for lots of reasons. We've kind of highlighted our growth and total joints, we've seen similar growth in spine cases and clearly cardiac is a moving service line from hospitals to outpatient facilities. And so when we look at our growth opportunity, our recruitment is focused on those specialties. You could see that showing up in our net revenue per case numbers and we believe that transition continues. Obviously, hips are getting added next year from a CMS standpoint and the acuity opportunity for us remains quite large. So from that perspective, we're pretty excited about that. I would also say that on the commercial standpoint, as far as our rate goes, the commercial standpoint we feel that there's still a lot of opportunity there. As we add higher acuity services, the one thing I would point out is our value proposition gets stronger. Because that differentiation we offer from a value perspective on higher acuity surgeries allows us to work with payers to create value for both sides. And so we continue to see that as an opportunity that we have not fully taken advantage of. But we've made progress and I'm really proud of the commercial rate progress we've made. So I would reiterate what Wayne said, we also feel really good about our acuity, position recruitment is backing that acuity because we're focused on those positions as we've talked about from a data-driven perspective, that they’re the highest quality and move those procedures to our facilities. And then lastly, we certainly feel like there's still a lot of opportunity for us to share more of the value we create with payers as we as we raise our high acuity services.

And Tom, maybe just elaborate that now we're really in a position to start that third pillar more offensively now. And maybe you could talk about what's available from a liquidity perspective?

Yes. There's obviously a lot of cash on the balance sheet at September 30 and some of that is obviously the advanced payments that we’ll start repaying in small part in the second quarter of next year. But as we think about the capital that we've recently deployed and we think about the liquidity that we have available, I'd say our goal, we've talked previously about wanting to deploy $100 million a year to try to build up that M&A pipeline and to build up that third leg of the stool. I think we still have the capability to deploy $100 million to $150 million over the course of the next 12 months to help generate incremental earnings.

Great. This is great color. I'll go back to the queue. Thank you.

Our next question comes from line of Bill Sutherland with The Benchmark Company. Please proceed with your question.

Hey, good morning. Thanks for taking the questions. I have one question. How do you guys think about the likely impact of seasonality this year of being so unusual and copying against a more normal fourth quarter last year? Thanks.

Hey, Bill, this is Eric. Appreciate the question. And it's a good one, right? I think that, this is the first, fourth quarter, we've had post a pandemic. So I have a little bit of a humbleness on our ability to predict this. I would say that early on, it looks like a normal fourth quarter, as we talked about. So we're seeing our trends year over year comparatively, matching up with what we've been seeing in the third quarter, which makes us feel good. There are a couple of offsetting factors, as you might guess, you know, you think about, there may be less pressure or maybe less opportunity for people who've met deductibles. But there are also a fair number of people who may have waited. And so it's, as we see some of our lower acuity service lines like GI recover, we still think there is some of that fourth quarter push, we're seeing that obviously. And so until we have data to prove otherwise, it looks like a normal fourth quarter, but it's I will keep a little bit of a COVID unknown there that we just have to be aware of, but we're obviously planning as if it is and so far, so good.

Understood. And then if I could sneak one more in on as you guys think about the potential impact with the additional procedures that Medicare is now reimbursing. How much of a factor is that as you look into next year?

Well, it clearly it clearly opposes our competence as we think about our double digit growth rate. And it's hard to know whenever CMS first puts out procedures; it takes a while for physicians to embrace it. It varies by market, how fast it's embraced. We do think the general sentiment among physicians to move higher acuity procedures to our facilities has increased dramatically during the COVID shut down. So you know optimistic about it, it certainly gives us confidence in our ability to continue on our double digit growth platform. And we see it as an upside for sure.

Hey, Phil, one thing I want to add and good morning, by the way, is one of the things we take pride in as a company is how we are data driven in so many decisions making. And yesterday, we spent a decent amount of time as a board of directors, with our management team, talking about the splitter, as we refer to it, where we have individuals that are doing commercial business, in our facilities today, but have a fairly sizable book of Medicare business that historically could not be done in our facility. And I will tell you, the opportunity is quite vast, with physicians that are with us already. And so the concept that as Eric said, I think we have a whole new wave coming in of not just the positive recruiting efforts of what we are doing as a company. But the idea of really getting to the pain points for surgeons as to what will it take for you to move your Medicare, your splitter business, if you will, over to our facility, and a lot of it comes down to what we've said over the last two years, which is they want block time. And they want turnover time quickly in those rooms. And that is the one thing we excel at. And so I'm with Eric, I think the opportunity is vast, but I want to make sure you understand that the team is really at a granular level of data driven approach then on how to target not only what is available to us, but what's really in our backyard today that we can now pursue with physicians that know our facilities already and know our nurses already.

Good. Thanks for the color guys. Appreciate it.

Thank you. Our next question comes from line of Ralph Jacoby [ph] with Citi. Please proceed with your question.

Thanks. Good morning. Just want to go to 2021? Sounds like you're comfortable with double digit growth? You know, first, I don't know if you're willing to sort of narrow that at all. Is it sort of low double digit from this vantage point? You know, are you talking teams at this stage? And maybe if you can also help with sort of a baseline? Is it, do we consider that off the 250 to 260 or do we need to make adjustments and think of a different baseline?

Hey, Ralph. First of all, good morning and so this one's a tricky one that's easy to answer, though. It's not off the 250 to 260. It's what a pre COVID baseline would look like. So clearly, we fully anticipated our year being stronger than 250, or 260, when we started this year. And so in the simplest math I can give you is, we're not going to commit to whether it's low double digits or teens or anything, what we will tell you is we've been very consistent in saying you can look at where we finished last year at. You can add 10% to that for this year, you can add another 10 for next year and you can kind of do the math, and that ought to give you at least a baseline of what we see is our targeted growth rate and so clearly based on the 250 or 260 that percentage of growth will be much higher than low double digit. So I want to give you the right baseline, but I think just take last take 19, add double digit to what would have been this year and add double digit to that. And that's what we went to spent [ph] for 2021.

Okay, very, very helpful. And then, you know, I guess this quarter, you didn't see as much margin pull through and a pretty hefty top line print. Is that just the higher cost that comes with acuity? Did you have other costs in the quarter? Or does it reflect you know, some of the sales or divestitures that you did? And maybe just how you're thinking about that kind of margin trajectory at this point? You know, obviously, expansion sounds like it given the growth that you put out there, but just any way to sort of frame how you're thinking about the margin expansion opportunity? Thanks.

Yeah. I really appreciate that question, Ralph. That's something that we spent a lot of time and let me first start by giving the simple answer the margins are actually strong. And it's exactly what you highlighted. If you were to look at three items, one is if you look at the mix, as you know, we focus on highest dollar contribution, dollar per minute, not margin. And because of our higher mix and total joints, and how much we're growing those, as you know, the accounting for those puts the full cost of the implant both in the revenue and in the COGS. And as a result, it artificially creates what looks to be a lower margin, when in fact, if you were able to strip out those COGS components, you would see the margins are even much higher. Second thing is keep in mind that our highest margin business is very low acuity, which is GI and GI is the slowest to recover of all the factors out there. Now, we saw it get much stronger by September, those trends are continuing in October. So I think you'll start to see just a mix of the higher margin lower acuity businesses coming back in and then finally, I don't want it to be lost some of the comments that Eric made in the opening remarks, but we are making a lot of investments in the business. We see a very unique opportunity to really accelerate certain investments to really drive further value and Q3 was a strong quarter and we chose to make those investments in this quarter. And, if Q4 continues as we've seen in Q3, we will probably make investments then as well.

Okay, great. Very helpful. Thank you.

Thank you. Ladies and gentlemen, our final question today comes from the line of Brian Tanquilut with Jefferies. Please proceed with your question.

Good morning and congrats on the quarter. So most of my questions have already been addressed but I guess I've got a couple. On robots, how are you thinking about the rollout of that? And how should we be thinking about the CapEx required for that, and if you can throw kind of like a number more or less that you're thinking in terms of the robot strategy, as part of the recruitment process for docs?

So I'll let Tom talk a little bit about kind of the financing of it, I would say this, Brian, just to give you a little context. We have a lot of markets, where we have physicians who use our facilities today, who have additional cases, they would bring with the appropriate technology, often robots, and we look at each of those markets, you know, independently to decide if it's the right investment to earn that business. And we're finding more and more markets where that make sense. It's high acuity business, its new business; it's able to be done in our facility safely. And so it's about existing docs also, expanding their business, it's also a way to open our doors to procedures in a book of business that we just didn't have the opportunity to get in prior times. And so we're working closely with managed care companies and our partners at health plans, working closely with the local markets, to ensure that it's accretive. But ultimately, we see real opportunity to grow acuity, earn business, move it from a higher cost setting to a lower cost setting. And actually, you know, a lot of winners there. The healthiest is the winner, the patients, given our patient experience scores are winners, the physicians like it. And so market by market, we're making those investments you've seen this year, it's been a pretty dramatic increase there. And we actually do see big books of business when you think about how physicians are trained, big books of business, in ortho and spine that are growing, but also when you think about Da Vinci, it's general surgery, it's basic GYN. And so we're going to be aggressive and finding ways to compete for that business and provide the value we can uniquely. So I don't know Tom, if you want to talk a little bit about the investment profile.

The installed base of robots that we have is probably in the range of 25 to 30, across the portfolio, right? And it'll probably be close to that of that high end number by the end of the year. You know, as you think about that, we've been adding them into some of our ASCs. But in particular, because a lot of those are in the surgical hospitals today, we added a handful of Nico's [ph], for example, this year. A, the vendors have been working with us and we obviously have financing capacity for these. The economics on the pilots that we've done at the ASCs have been quite promising. And so well, I don't see us, putting a robot in every facility, we are going to think about every facility where it makes economic sense to drive EBITDA, in those multi-specialty centers where this is going to have a good ROI. And so we're piloting it now, we're expanding it but the early read looks quite good.

That makes sense. I guess, follow up to that to a question from earlier. In your prepared remarks about, salaries being down, year over year, how should we be thinking about the durability of the cost structure from this point on? I mean, from a modeling perspective, obviously, we're seeing organic growth, acceleration are picking up right and you've obviously flexed your cost structure during the pandemic, so how should we be thinking about the growth on the cost line, other than supplies going forward?

You know, I'm hard pressed to say that I think we're going to keep all of it because I think a little bit of it as a function of how we manage the shifts in light of the lower volume. But I would say that I've been extremely impressed by our operators ability to take a hard look at their cost structures in the midst of this pandemic. And I think that some of the changes that we've made are going to be durable. And so you know, we're actually, obviously the mix that Wayne talked about with the higher acuity procedures passing through the cost of the implant, you know, lowers the percentage margin, but we continue to believe that we've got run rate cost efficiencies that are going to be durable but have come out of some of the restructurings that we've done across the portfolio over the course of the last six months. And we have other initiatives underway that we think will deliver additional G&A cost savings over the course of the next calendar year. So we continue to really go after those costs to try to provide a better service and be more efficient for our customers or our surgical facilities.

Brian, one thing I want to add to. I think it's sometimes gets over looked but I'm really proud of what this team has done. The core infrastructure investments that had to be made when we started in 2018 with this journey, there was not a data warehouse. Today, we have over 97% of all of our facilities on a single data warehouse. So as we do acquisitions and expansions now, we are migrating them on day one. That's our priority. We did not have a single HRS system. So the fact is that today, over 95% of our facilities are on a single HRS system. What does that mean? We can flex up and down now, our nurses, our staffing models, et cetera, based on facilities and we can look at it real time. And that did not exist even six months ago. We have been doing all the heavy-lifting the last two years to do that migration, which we did in the first six months of this year and that's where we're at today. And so yesterday as a board, we got to actually see real data that gives us even more agility, flexing up and down. And then revenue cycle management, as Tom talked about, those investments are almost completely behind us now, and so we're finally at the stage now where we get to capitalize. We actually get to capitalize on those investments and I think over the next year from a G&A perspective, there's tweaks on like, 'Oh, there might be a little more investment here, a little bit more here.' But that heavy-lifting investment and that kind of running dual systems, and processes and people running manual while we were also trying to build the platforms, that is now substantially behind us. And so as we go into next year, I actually think to Tom's point, I think there's a lot of sustainability in the G&A structure even with the growth platform coming and we ought to see even more value creation now having better data.

Now, that makes a lot of sense and Wayne, it's actually a really good segue to my last question. It seems like everything's finally clicking. I mean you had to do a lot of heavy-lifting from 2018 through 2019, had to run through COVID and now, it's finally clicking. So you talked about that part of the strategy, talked about organic growth, picking up M&A, going back to that well. So we put all that together and it feels like we're getting ready to see an acceleration in overall growth to what, maybe a mid-teens level? Is that a good way to be thinking about overall EBITDA growth?

You know, Brian, first of all, let me just say, you couldn't have said the words better. Everything is clicking. We're at a point and we all said as a management team this quarter, we kind of hit that sweet spot and we got rid of the last few distractions. That being said, COVID is such a big unknown. And I just don't want to get over my skis because the fact is, volume is still down versus last year. And so the question is, can we grow out of it faster than everybody else so far? We think the answer is yes. Can we take advantage of that then to really get that more accelerated growth? I would say all the tools in the toolbox are there now and it's just a question of how do behaviors change in this post-COVID environment and we're ultimately -- we land as a as a country around those behaviors. So all in, I would say the optimism is there. I would say we got a preview of next year's with management and we like the number of initiatives we have in front of us. I'll leave it at that. I think as a management team, we think it's always prudent though just to commit to double-digit and just deliver and if we can outperform that low end, then great. And so right now, I think we would not probably get ahead of ourselves until we see how COVID and the pandemic plays out.

Now, it makes sense. Appreciate it. Thanks again.

All right, appreciate everyone's time today. Before we conclude our call, I also want to take a moment to say thank you to our 10,000 plus colleagues and 4,000 plus physicians for their contributions. Surgery Partners collectively serves over 600,000 patients each year and thousands of patients each day and what are often their most vulnerable moments. We take that trust and faith that our physician partners and patients place in us incredibly seriously and our privilege to make a positive difference in so many people's lives. I am excited about and humbled by the opportunity to lead this company as we work to more fully deliver on our mission of enhancing patient quality of life through partnership. In our efforts we're clearly part of the solution to many of the challenges facing our nation's healthcare system and are extremely proud of the value we are creating for all of our stakeholders. As we execute against our goal to become the preferred partner for operating short-stay surgical facilities across the U.S., it is the daily efforts of each and every Surgery Partners' colleague and physician that will help us get there. Thank you for joining our call this morning and hope you all have a great day.

Thank you. This concludes today's conference. You may disconnect your lines at this time. Thank you for your participation.