Q1 2021 HCA Healthcare Inc Earnings Call
<unk> earnings conference call opening remarks and introductions.
I would like to turn the call over to your Vice President of Investor Relations. Mr. Mark Kimbrough. Please go ahead Sir.
Alright, Thank you Kara and good luck.
Sam and Bill.
Okay.
Provide some prepared remarks, and then we'll take questions afterwards before I turn the call over to Sam.
Bill, let me remind everyone that should today's call contain any forward looking statements.
They are based on management's current expectations numerous risks uncertainties and other factors may cause actual results to differ materially from these.
From those that might be expressed today.
For information on forward looking statements and these factors are listed in today's press release as well as on our various SEC filings and GAAP financial measure.
A table providing supplemental information.
Ali.
Net income attributable attributable to HCA Healthcare, Inc.
It is included in today's release.
This mornings call is being on.
Now I'll turn the call over to sales.
Alright, Thank you Mark good morning to everyone and thank you for joining us as.
As the COVID-19 pandemic continued to surge we started the year with strong financial results and the first quarter.
The results were driven by better than expected revenue growth and improved operating margins.
Revenues grew over one 1 billion or eight 7% as compared to the prior year.
This growth was generated by highly.
And the acute inpatient volumes better payer mix, and a rebound and surgical and outpatient volumes in March.
Generally speaking March trends are continuing into April.
And patient revenues increased by 12% the acuity within our inpatient business was higher as reflected in both case mix index, which increased 7% and length of stay which grew by 6%.
Additionally, commercial admits and sort of our domestic operations represented 29% of total admits compared to 2000.
And a six 5% last year.
Commercial payer mix has been consistently around this level for the past four quarters.
These two factors combined explain a 17% increase and inpatient revenue per admission.
Total debt total admits were down for 2% year over year and comparison to 2019 admits were down approximately 3%, which was which was in line with our expectations.
And the quarter, we treated almost 50000, COVID-19, and patients which represented 10% of total admissions.
Throughout the quarter the percentage of COVID-19, Admins to total admits decline January was 17% February was 8% and March was down to almost 5%.
Outpatient revenues increased four 7% as compared to prior year.
This result is better performance than the previous two quarters, and which outpatient revenue was down approximately 5%.
Outpatient revenues declined in January and February consistent with that trend, but March which had one additional week day this year.
Increased by 30% as outpatient surgery and other procedures recovered strongly.
Same facility outpatient surgery volumes grew two 3% as compared to last year since declined 18%. This decrease is generally consistent with the trends we've sent compared to 2019.
Our teams.
We continue to focus and deliver on our operating agenda.
Adjusted EBITDA margin for the company grew on a year over year basis and was consistent on a sequential basis with the prior quarter.
Diluted earnings per share, excluding losses and gains on sales as well as losses on debt retirement increased 78% to $4 14.
During the quarter, we announced the definitive from health and hospice business.
Of Brookdale senior living.
The large platform that complements.
And it's our local provider systems.
It will expand the services we offer across our.
For networks and provide us with more enterprise capabilities to coordinate care for our patients and improve their experiences.
Additionally, we believe the whole will become a more important setting for healthcare and the future with continuing growth and demand.
We anticipate this transaction will close in the third quarter and we look forward to our new partnership with Brookdale.
Also during the quarter, we opened two new hospitals, one in Denver and one in Orlando each of these hospitals will strengthen our system offerings and these communities.
And the second quarter, we expect to close on the acquisitions of two small hospitals, both of which complement our networks and Nashville and Savannah.
And lastly, we continue to invest broadly across our networks to improve convenience access and value for patients by developing more outpatient facilities.
The pipeline for development and acquisition and this category remained strong.
As we look to the rest of the year, we have increased our annual guidance to reflect the first quarter's performance and better perspective on important macro factors, mainly governmental reimbursement and economic outlooks for our markets, including uninsured assumptions.
Bill will provide more details on our guidance in his comments.
The first quarter is yet another period, where the disciplined operating culture and strong execution by our teams were on display.
And I want to thank our 275000 colleagues and 50000 physicians for their tremendous work, we could not have performed at this level without their unwavering commitment to our patients and the communities we serve.
And as we continue to resource and execute on our strategic agenda, we will remain true to our mission of improving lives and.
And.
Delivering on the responsibilities we have to all our stakeholders.
And now I will turn the call over to Bill.
Good morning, everyone same spoke to many of our operating metrics and results. So I will discuss our cash flow and capital allocation activity. During the quarter, then review our updated 2021 guidance as.
As a result of the strong operating performance and the quarter, our cash flow from operations was one quarter of 2020 <unk>.
Capital spending for the quarter was $654 million and we completed just over one 5 billion of share repurchases during the quarter we.
We have approximately seven 3 billion remaining on our authorization and consistent with our year and discussion. We are planning on completing the majority of this and 2021 subject to market conditions.
Our debt to adjusted EBITDA leverage was 285 times and we had approximately $5 6 billion of available liquidity at the.
We ended the quarter.
As noted in our release. This morning, we are updating our full year 2021 guidance as follows we expect revenue to range between <unk> 54 billion and 55 5 billion.
We expect full year EBITDA to range between 10, and eight 5 billion and $11 35 billion.
We expect full year diluted earnings per share to range between $13 30, and $14 30.
And our capital spending target remains at approximately $3 7 billion.
Our revised guidance considers the strong results and the first quarter and also considers the extension of the public health emergency and the deferral of sequestration reductions through the end of the year.
In summary, we recognized some uncertainties remain as we go through the balance of the year, but we are confident and the companys ability to manage through various business cycles, and we are well if they become available so with that I'll turn the call over to Mark and and open up for Q&A.
Alright. Thank you Bill Thank you Sam Kara.
And going to open up for questions.
Please remind everyone to limit their questions to one so that we might keep trying and gives many and the queue as possible.
And as a reminder, if you'd like to ask a question you may do for by pressing star one on your telephone keypad.
For just a moment to compile the Q&A roster.
Sure.
Your first question comes from the line of Tito <unk> with Deutsche Bank.
Okay.
Okay.
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Vito Vito and Youre breaking up I can't hear you.
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Care and <unk>.
Let's drive the next one Pedro track Hollenback.
Your next question comes from the line.
Your line of Kevin and Mitch.
And with Bank of America.
Great. Thanks.
I guess my question would be on guidance. Thank you.
Okay.
For clarification.
Your guidance I assume does not include the two deals you expect.
Thank you for your Q or the Brookdale acquisition, and then more to the point as far as guidance. How do you think about the upside yet to ship and.
It sounded like a lot of the range because of sequestration and essentially all day.
And <unk>.
And then how much of this outperformance and guidance range do you think and.
Kind of one time versus things that we should be thinking about as you have and have better visibility into future growth and 2022, and 2000 and great. Thank you.
Thank you Kevin Kevin Let me answer that first.
Youre right the acquisitions for the balance sheet are not included in our expectations, but we don't expect that material contribution from those for this year.
Relative to our increase in guidance.
Largely due to the strong performance that we had and the first quarter is the driver of that.
As Sam talked we have some insight into March and the read through through April and then we did consider the continuation of the deferral of sequestration through the balance of the year and we know the public health emergency got extended at least through 90 days to July so the majority of the guidance.
Range is the result of our performance from the first quarter and considers the.
And the extension of the sequestration on there so.
As we've talked about it and our year end call Theres still variables out there but.
And the way we are reading the environment right now and is generally positive.
Thank you Kevin.
Kara.
Next question please.
Your next question comes from the line of Frank Morgan with RBC capital markets.
Margins, and obviously big expansion year over year, and you sustain nice margins from the previous quarter, but can you just give us any more color around the dynamics of your ability to continue to manage cost and this way and it really look like it was across everything labor supply.
The other is it more of a function of just the top line growth or is there something structural on the cost side thats, allowing you to take advantage of having flex labor just any color there would be appreciated. Thanks.
Yes, Frank This is bill I'll start I think the margin is primarily attributable to the top line with the revenue and the acuity and the payer mix that we had.
But we continue to be focused on looking for efficiencies throughout the company as we've talked about our resiliency plans and the past.
And so those efforts continue and many of them are well underway.
And almost every category and so that is a part of the performance of the company, but the margins clearly are being helped by both the acuity and payer mix and the revenue per adjusted admission that we're seeing but as we've talked about multiple times. We are continuing to look for as much efficiency as we can as we go through different cycles and <unk>.
Many of those efforts continue to be underway.
And Bill if I can just add to that our cost per adjusted patient day was in line with our expectations and actually.
Slightly underneath that and so we were already seeing in the face of really a difficult labor market, 3% growth and cost per adjusted patient day. So I think it's a.
Combination of both but obviously with.
The mix that helps frame alright, thank you for rank.
Thank you.
Sure.
Your next question comes from the line of a J rice with credit Suisse.
Hi, and variety.
Maybe just to ask a little bit more about the capital deployment opportunities on our last quarterly call you guys had mentioned cash.
And we'll do some post acute care dynamics and then obviously net the announcement about brookdale, perhaps that was what you were alluding to last quarter, but <unk>.
Maybe talk about your appetite there and whether you are seeing broader health systems, I know you get to honest little deals, but and maybe broader health systems. There was some thought that they might.
And look to partner on coming out of the pandemic have you seen any.
Uptake and activity there and then finally on the capital deployment.
Spending around your Capex.
And moving and you are still emphasizing access points, but I wondered whether investments and Edr and for example might be diminished given what we've seen coming out of the pandemic and lot of <unk> activity and maybe diverted some of that money elsewhere.
Just some comments on capital deployment opportunities.
Okay, a J D.
And Sam I'll try to respond to those and I'll remember all all the elements for us on post acute let me speak to that obviously, the home care opportunity and hospice opportunity to US. We believe is a significant expansion of the services, we offer and the opportunities for.
Integrating those patients who are discharged and we discharged about 250000 patients a year into home care.
<unk> and opportunity for us to coordinate care better steak.
Stay connected to the patient after they leave our facility and ultimately integrate them more effectively and to HCA healthcare system. So we see a nice broad opportunity. We believe homecare provides multiple channels of value for us some of which are and the discharge is that we talked about some of its and better cash.
Management and discharge planning and some of it is staying connected to the patient when they repurchase healthcare also on post acute we have mentioned before because of the CLA and relaxation and Florida, we use opportunities do the same thing with.
With rehab and so we've invested somewhere between 250 and $300 million.
Or we are investing rather.
And developing rehab services and the state of Florida, which will expand the offerings.
And those markets to our patients and support our systems. So we still see potential in both of those areas to expand into.
More significant relationships with Medicare advantage payers potentially on post acute.
So it creates opportunities for us and multiple ways.
As it relates to <unk>.
And our capital spending as we mentioned and our guidance for 2021, we are increasing our capital budget to somewhere around $3 7 billion much of that increase is related to growth projects, where we are expanding at facilities, where we need our facilities are north of that and so on and <unk>.
Order for us to capitalize on this differentiated portfolio, we have where we believe our markets have unique growth prospects because of great economies population growth.
And so forth, we need to create capacity both on the inpatient and certain circumstances and build outs and networks. Additionally, with outpatient facilities.
As we mentioned.
With respect to ER specifically.
We do see ample supply generally speaking.
With our ER beds today.
And we'll have some continued investments and emergency room supply and capacity across certain markets because.
Number one and but they're not nearly as significant as they were five years ago. When we were investing more heavily and that so that flexibility will allow us to invest and ambulatory surgery centers, where we have a tremendously strong pipeline for new development. I think we have 10 or 12, new ambulatory surgery centers that are under development.
And we have a robust pipeline and that particular category as well.
And then we will also invest and urgent care and recognizing that that continues to serve a role and building out the capabilities inside of our markets and.
As it pertains to M&A.
I do think there are going to be opportunities as we've mentioned in the past they come when they come its hard for us to predict we are fortunate to have a balance sheet that can take advantage of those opportunities as presented we have enterprise ch<expletive>is. If you will.
That is built to be bigger and to bolt on new opportunities and create synergies and value inside of those centered by our systems and so we will continue to look for those as they develop and hopefully find opportunities that make sense for us. Thank you.
Great. Thanks, Thanks AJ.
Your next question comes from the line of retail share Green.
Green with Deutsche Bank.
And one more traffic.
Can you guys hear me now yes, we can hear you take too so thanks for taking my questions.
Can you give us the components of the 2020 one guidance raise how much is due to the strong first quarter. How is it due to additional government funding any changes for the back half of the year and as you look at the margins for the back half of the year Youll face tough comps and good pricing and mix due to COVID-19 and the payer mix typical trends and labor.
Alright.
Yes.
Yes. So this is bill let me, let me try to zero and on that.
Answered Kevin's number the majority was due to the strong performance.
We understand we beat our expectations and depending on your number of anywhere from 300 $400 million.
And we expected the first half of the year to be stronger than the second half, but it's still outpaced our expectations.
Sequestration extension.
For the end of the year is probably worth anywhere from 40% to $50 million per quarter, so that debt.
And that we originally did not anticipate that continually and p<expletive>ed the first quarter. So that's an element of the of the range too. So if you look at the midpoint of our range was $500 million you can say, it's probably $3 50 to 400 from our performance and and the balance through.
These government extensions if you wanted to have specifics on that but we also have a range with variables that are.
That continue to play out on the margin question, Yes, you are right and when we gave our year end guidance. We said, we anticipate our margins to likely look a lot like the full year 2020.
As.
We began to kind of see the second half of 2020.
And really with the strength of the payer mix and acuity. So we're very pleased with where we stand with that will continue to to evaluate as the year goes on but I think the balance of our guidance I would reflect back to our discussion at the end of the year. So so the rate really is the consideration of the strong performance and the first quarter plus the continuation of the.
Government support and <unk>.
Bill This is Sam let me, let me add one thing to that I mentioned, just a second ago that I think we have a differentiated portfolio and inside of that differentiation. We believe that the growth prospects for Austin, Texas, Dallas, Texas, Miami, Florida places like that are much better than the national average and so we continue to see job.
Growth the other thing I would point to.
Is that the increase and enrollment through the exchanges is a very positive dynamic and we see further opportunities for improvement and that particular dynamic as theres more money supporting navigation and other support for individuals who have lost their job or participation and exchange.
<unk> has improved year over year, and actually significantly improved over 234 years to where we have roughly 80% access to exchange lives across HCA markets today, which is quite different and what it was maybe three or four years ago. So as more people will get enrolled there we think the support and.
And this is one of the things we've talked about in the past how does the affordable care Act provides support and a recessionary cycle and it seems to be providing solid support and as we look forward that is an area that we find to be a positive dynamic as well.
Okay. Thank you much.
Kara your net.
Your next question comes from the line of Ralph Giacobbe with Citi.
Alright.
Hey, guys.
So our outpatient surgery up two 3% stand down.
And maybe just what's driving that category kind of book the negative volume trends and then and then Kim you mentioned, 30% on the outpatient side and more to RBC.
Pretty healthy number so just hoping you can give more detail on the categories, there and maybe the impact of the influence.
Whether I'm, <expletive>uming some of that maybe pulled forward from from weaker February but any commentary on that would be helpful. Thanks, alright. Thanks Ralph.
Folk.
Obviously the March this year had a favorable calendar we had one more work day than we did last year last year August will be shut down the company for the most part midway through the.
The month, but when we look at March 2019, we saw activity levels that were consistent on a per business day. So the outpatient surgery activity in March of 2019 per business day was pretty much identical.
For the outpatient surgical volume per business day in 2021.
Yes, it's probably a little bit of pull through from February storms, but for the most part we were up and operational and a week and the state of Texas, which was a remarkable feat on on the part of our teams.
And so I don't know exactly how much of that was storm related it's hard to really pinpoint that but where we're seeing obviously a little migration from inpatient to outpatient which has continued from from one year to the next and that's influencing our outpatient statistics also but when I look broadly across outpatient.
Volume not just surgical and cardiac volume very strong performance and electrophysiology on the cardiac side.
Recovery and endoscopic procedures on the outpatient side. So some of the diagnostic activity, which we believed had been deferred it showed itself a little bit in March and ways that we can.
Hadn't seen may be and other months in the latter part of 2020.
So we're encouraged by that as I mentioned and my comments were seeing some pull through into April that's very similar and we will continue to monitor this and report out on it and give you a better feel as we get further end of the year.
Thank you are out and we thank you.
Thanks.
Yes.
Your next comes from the line of Lance Wilkes.
With Bernstein.
Yes, Thanks a lot.
And I just wanted to ask about two things as were starting to move into kind of post COVID-19 impacted period was interested and what are you able to do from a capacity expansion standpoint kind of within facilities and within outpatient to accommodate more volumes kind of the catch up on deferred cash.
There maybe for the second half of the year to understand how that capacity could expand and then just also interested and bad debt.
Performed during this period and and the activities you've taken as far as kind of a collection or other sort of processes to deal with that and how that looks going forward.
Okay, let.
Let me take the first one and I'll kick the second one for Bill.
With respect to capacity management, a couple of things one as I mentioned, we are investing.
To expand capacity, where we believe appropriate both inpatient and outpatient emergency room, whatever the case may be we have a very sophisticated analytical methodology to determining where do we have constraints and where do we have opportunities to relieve those consumer strength with investments and so forth, but the second thing I would say and I think this is an important point.
And it's and learning that we experienced during the Covid year I'll call. It 2020, and the first part of this year the ability to manage our capacity.
In order to deal with the different surges that we experienced that required us to hone our discharge planning process and case case management function and see a spike.
And to show itself I think the loans.
And from our capacity management standpoint that we experienced and gained during the Covid surges will help us.
Cooler situation. So those are the two approaches that for.
We are doing to deal with.
Potential growth and demand and we still continue to believe that long term healthcare demand is there and and.
And it will be there and the future and our systems are durable and built for that.
That as we.
Continue to move through these different period.
Yes on the on the bad debt and the uninsured I think as we reported in the past we've continued to see declines and our uninsured volume as the Covid pandemic.
And the show itself all throughout the last three quarters of last year and that continues into into the first quarter and those uninsured declines are greater than our total. So some of that is also due to we are receiving some purse of payments for some reimbursement for uninsured COVID-19 patients. So all of those have.
Resulted at our uncompensated care levels are actually below where we were running prior year and.
We don't see any material developing trends and that category. So we're very pleased with where we stand relative to the bad debts and the uncompensated care physician alright. Thank you Lance Inc.
Your next question comes from the line of Scott Fidel with Stephens.
Alright.
Net.
Strategy and and interested that you guys had mentioned the interesting statistic that you have around 250000 patients discharged annually directly into the home interested if you've been able to evaluate what percentage of those patients would be covered by the existing book Brookdale home health footprint and and.
And if you think about markets, where you have don't have the overlap with Brookdale and whether you would look to scale up that <expletive>et or whether you would consider pursuing additional strategic relationships with other providers.
Providers.
Alright, Thanks, Scott, Yes, Scott on the Brookdale, roughly 60% to 70% of their agencies have overlap and our market. So obviously that was an attractive strategic component of the acquisition and as we worked through the acquisition and integration we're going on.
Explore that.
For that even further relative to.
Agencies that reside and non HCA markets.
We will still evaluate what is the appropriate course of action and if there are partnership opportunities we may pursue those book.
Thanks Scott.
Sure.
Comes from the line of Brian.
Thank you, Matt <unk> with Jefferies.
Hey, good morning, guys. Congratulations on a good quarter I guess my question for you Sam as we started seeing that the pace of recovery how are you.
And thinking about remaining pent up demand and the market and then as we talked about payer mix earlier.
What can you share with us in terms of the mix of patients you're seeing both on the kinds of procedures, we're seeing with the recovery in March and April and the payer mix bucket that we're seeing is it shifting back to.
And more Medicare more uninsured and more Medicaid and I just wanted to see if you can give us some color on what the recovery looks like right now Thank you alright, Brian and thanks.
Well I think.
It's still early to land on exactly what the recovery.
Free it's looking like if you look at the two elements of our business, where we saw a significant drop off pediatric activity on one side and then obviously Medicare activity on the other so the middle piece, if you want to call it that having said that most.
Our outpatient business that was deferred is that we have lost is the outer shoulders, the pediatric and the Medicare side of the equation.
So I don't really have a good sense of what's going to happen on the Medicare side, we're starting to see more pediatric activity in the month of March it wasn't down as much as it was in previous periods, which reflects I think kids going back to school and many communities activity starting to happen again with.
Spring sports and such and we're seeing a little bit more traffic and our emergency rooms related to pediatric volume, but I think on the outpatient side, which is where most of the deferred care. We believe was.
That is largely a commercial book of business, 55% of our revenues.
And so on the outpatient side as commercial related and as that starts to develop we think that will be probably what shows itself from the deferred care, but it's still early obviously.
But theres still uptake with vaccines.
There is still.
Concerns with Covid from one community to the other and all of that could create some choppiness to it all but we need a few more months to really judge exactly what that rebound is going to be but we're encouraged again by March we're encouraged by the early view into April and we are.
Hopeful that that sustains itself over the remainder of this year.
Alright, Thanks, Brian.
Your next question comes from the line of Justin Lake.
Welcome to research.
Hey, Thanks, good morning.
Hey, good and try to squeeze in two court numbers questions here, if that's okay for us given the meaningful shift in 2021 numbers. Obviously the positive wanted to ask about the right jumping off point going into 2022 in terms of moving parts and we know how.
And just one I could take average sequestration is probably going to come back maybe offset price and acquisition benefits et cetera. So if you could run through that that'd be great and then on the commercial mix shift given how dramatic it's been I was wondering if you have any ability to parse that out in terms of market share gain versus just the population shift and younger people moving south.
And your market and simply just less deferred care among commercial populations versus maybe Medicare. Thanks Jud.
Just and I'll start with the first one on that.
It's early for us to be thinking about the variables going into 2022 as we were just talking about trying to get a read on how the recovery period, if you will or how the how how the business settles once COVID-19 gets to a normalized level. So it's just a little early to think about the puts and takes of 2020.
Two we don't have insight into government funding and beyond this year at this stage so.
Give us another quarter or two and then as we near the completion of the year, we'll be able to talk to you about our view.
The trends, we're seeing currently and as far as how they roll into 2022 and.
And adjusted this is Sam on the market share.
We are operating at an all time high on market share based upon the most available currently available data, we have which is at the end of the third quarter.
For 2020, and we are pushing the overall market share for the company across the 43 domestic markets into.
And to the low 27% zone, so very high watermark on the commercial side of the equation.
We have in fact gained market share on the commercial at an even faster pace.
No exactly how thats playing out in the fourth quarter and the first quarter, but we have seen trends that are more positive for our company.
On that particular front and our overall trends and I think thats been part of our results and we continue to evolve our physician strategy. Our service line strategies, our outreach strategies and so forth toward the commercial book of business as you would expect and we believe it's yielding a positive result for the company.
Alright, Thank you Justin.
Your next question comes from the line of Josh Raskin with net Brian.
Hey, Josh.
Thanks for taking the question just had a quick one on capex. It looks like Capex was actually down almost $200 million year over year and the first quarter, even though you are guiding to considerably higher capex for the full year. So I was just wondering what caused that Dick.
And this quarter and I don't wanted to see what the thinking was on how capex would ramp through the balance of 2021.
And we understand it was below some of that is the capital program starting.
We're.
Repopulate and a pipeline with approvals and so the spending of that you didn't see and the first quarter, we still believe that our capital spending will approximate this $3 7 billion.
And maybe a little bit on either side of that and so we do anticipate the capital the actual spend to ramp.
And as we go throughout the year and we'll just have to continue to evaluate that so and ultimately I think what youre seeing and the first quarters as we slowed down capital and 2020 as we began.
Re implementing some of our capital programs.
And just the spending didn't occur at that same level book, but we still believe $307 for the right number.
Just time and on how the capital gets spent.
Alright, Thank you, Josh even though I don't think Youre Josh.
Your next question comes from the line of John Ransom with Raymond James.
Hey, good morning team I have and exciting opportunity for you I'm going to ask two questions and you can either answer both the pick one.
We'll catch up on the other offline dealers choice.
First question is if we look at share <expletive>umptions for the back half of the year.
My hypothesis is that.
Certainly Medicare will grow faster than commercial but both buckets, if we measured by adjusted admissions will.
Growth just commercial and a lower rate is that consistent with your <expletive>umptions and my second question is.
And what is what are your top two or three public policy priorities and.
Given the new administration, so I'll stop there. Thank you.
John Let me take the first one our <expletive>umptions throughout the year, just consistent with our year and is that we do expect a recovery of our historical business to return.
As we see COVID-19 settle to a level as we hope broader populations gift.
Get vaccinated that will begin to see this return so so we do expect some growth.
To occur from where we are now as we go through the year and I think that is reflected and our full year guidance. The exact timing and the pacing of that is unclear, but we do expect throughout the year there'll be recovery and will return to <unk>.
Some historical level of pattern for us and and that would likely occur through all payer cl<expletive>es and Medicare as well as the commercial as we've talked about.
And we're going to play both of your cars. So the question around like a dream come true if I could.
Income true.
And just for you John and just really should have asked three questions and.
Okay.
Yes.
On the public policy front I think obviously, we're focused in on health policy.
And it's our belief that the affordable care Act is providing the support for the country that it was intended to do and we are hopeful that we can.
Maintain policies that provide that kind of protection for people. So they have that coverage and access they need and then the second area would be around tax policy. Obviously, we are a tax paying healthcare system as compared to many of our competitors aren't and paying.
And focusing in on getting to the right tax policy is important to us too. So those are weighted to category that we're that we're focused on.
Thank you John.
Have fun at the golf course.
Not today and my question is closed.
GAAP.
And our final question comes from the line of Jamie Paris with Goldman Sachs.
Hey, Jamie.
Good morning.
You've mentioned the March trends and that continuing into April I wanted to clarify does that mean the volume levels.
And we're in March and heading into April or.
The recovery curve and congrats in April and then more forward looking.
And what leading indicators do you look at what and primary care utilization and non Covid diagnostic Chinese debt and.
Yes, Mike and at some.
And some color on where volumes might go from here.
I think for the comment around April is as a general observation about our business as a whole and some of the aspects of our March.
Activity and result is carrying forward into April that's really all on what to say at this particular point and time.
For the second question again about leading indicators.
And we use our physician practices.
As a source of <unk>.
Leading indicators, if you will and we're starting to see new patient activity grow I want to say and the month of March new patient activity. Some of this business day, driven was up 17% over the previous year and that's a pretty significant indicator of future activity that occurred across a variety of <unk>.
Specialties.
<unk>, roughly 7500 to 8000 and physicians and so we're seeing activity within new patient rosters and new patient activity show up on our clinics and as I mentioned also our emergency room activity and started.
And grow a little bit from where it was and the low points in 2020 and during the Covid period. So those are two leading indicators that I would suggest R.
And indicative of maybe more activity is starting to percolate and the markets.
Alright, Thank you Jim.
Kara.
And there are no more questions at this time.
Alright, well listen and we want to thank everyone for joining the call today.
And I always feel free to call. If there are additional questions that you might have.
Have a safe day. Thank you.
And.
And.
And.
[music].