美股醫(yī)療保健行業(yè)二季度醫(yī)院總結(jié)uhs和的表現(xiàn)有所改善但不盡如人意

1、12 August 2019 Americas/United States Equity Research Healthcare FacilitiesHealthcare FacilitiesResearch AnalystsA.J. Rice 212 325 8134 aj.ricecredit-Caleb Harris, CPA212 325 7458caleb.harriscredit-Jailendra Singh212 325 8121jailendra.singhcredit-Eduardo Ron212 325 7491eduardo.roncredit-Q2 Hospital

2、Recap: Improved Performance for UHS, THC, and CYH, but a Rare Miss for HCAResults In-Line to Positive for Most Companies: Two of the four public hospital companies that we cover reported EBITDA ahead of consensus expectations. UHS beat by $15 mln and THC beat by $4 mln. CYH reported EBITDA in-line w

3、ith consensus, while HCAs EBITDA was $102 mln below consensus.Pronounced Volume Improvement for CYH and THC, While UHS Continues to Lead: For the second quarter of 2019, the hospital group reported SS inpatient admissions growth of 3.2%, on average. This represents an increase in the Y/Y growth rate

4、 of 170 bps sequentially and an increase of 320 bps Y/Y. UHS had the strongest growth in SS admissions at 5.2%, followed by THC at 3.3%. CYH and HCA both improved vs. the prior quarter with 2.3% and 2.1% SS admissions growth, respectively. The hospital group reported SS adjusted admissions growth of

5、 2.9% Y/Y, on average, in 2Q19. This represents a sequential improvement of 90 bps and a Y/Y improvement of 190 bps in the growth rate. UHS had the strongest SS adjusted admissions growth at 5.0%, followed by HCA at 2.6%, THC at 2.2%, and CYH at 1.8%.Q2 Pricing Metrics: The hospital group reported a

6、 Y/Y increase in net revenue per adjusted admission of 2.9%, on average, in the second quarter of 2019. This represents an increase in the Y/Y growth rate of 100 bps sequentially and is the same growth rate as in 2Q18. UHS had the strongest pricing growth at 3.5%, followed by THC at 3.4%, CYH at 3.1

7、%, and HCA at 1.7%. UHS said its medical/surgical mix normalized vs 1Q19.Outlook for Remainder of Year: UHS and THC maintained the key figures in their 2019 guidance. CYH increased its revenue guidance slightly due to an updated expectation on divestiture timing. While HCA missed expectations in Q2,

8、 the companys overall 1H19 performance was still strong enough that it raised both EBITDA and EPS guidance for the full year. We currently estimate that HCA will achieve 5.2% core EBITDA growth and 8.4% reported EBITDA growth during 2019.Updating Ms: With this note, we are updating our CYH mandtarge

9、t price. Our CYH target price is now $2.00 (prev $3.00). Risks to our ratings and target prices for all hospital companies include volume and pricing trends.DISCLOSURE APPENDIX AT THE BACK OF THIS REPORT CONTAINS IMPORTANT DISCLOSURES, ANALYST CERTIFICATIONS, LEGAL ENTITY DISCLOSURE AND THE STATUS O

10、F NON-US ANALYSTS. US Disclosure: CreditSuisse does and seeks to do business with companies covered in its research reports. As a result, investors should be awarethat the Firm may have aof interest that could affect the objectivity of this report. Investors should consider this reportas only a sing

11、le factor in making their investment decision.QUARTERLY獲取報告1、2、3、每周群內(nèi)7+報告；當(dāng)日華爾街日報、4、行研報告均為公開利歸原作者所有，起點財經(jīng)僅分發(fā)做內(nèi)部學(xué)習(xí)。掃一掃關(guān)注 回復(fù)：加入“起點財經(jīng)”群。12 August 2019Table of contentsSummary of 2Q19 Results3Company-by-Company 2Q19 Recap4CommuHealth Systems4HCA Holdings5Tenet Healthcare7Universal Health Services9Price P

12、erformance & Valuation10Industry Key Operating Statistics12Same Facility Admissions12Same Facility Adjusted Admissions12Same Facility Pricing12Margin Analysis13Expense Analysis13Financial Strength/Leverage14CommuHealth Systems (CYH)162Healthcare Facilities12 August 2019Summary of 2Q19 ResultsTwo

13、 of the four hospital companies under our coverage posted EBITDA ahead of consensus expectations.The major hospital companies reported SS inpatient admissions growth of +3.2% Y/Y (170 bps better than 1Q19).This was driven primarily by UHS, who reported 5.2% SS admits growth. CYH and THC saw signific

14、ant improvements on this metric. CYH improved 240 bps sequentially to 2.3%, while THC improved 340 bps sequentially to 3.3%.The hospital group reported an increase of 2.9% Y/Y in SS adjusted admissions (90 bps better than 1Q19). UHS was strongest in this category as well at 5.0% growth.Net revenue p

15、er adj admission (pricing) grew 2.9% Y/Y for the hospital group (100 bps higher than 1Q19). UHS also led this category with 3.5% growth, though THC was close behind at 3.4%.Figure 1: 2Q19 Results by CompanyHCAUHSRevenuesActualY/Y Change Consensus$12,602 9.3%$12,622$2,855 6.5%$2,807CS Estimate$12,622

16、$2,806EBITDAActualY/Y Change Consensus$2,293 3.0%$2,395$478 7.9%$463CS Estimate$2,362$464EPSActualY/Y Change Consensus$2.21NM$2.47$2.76 11.7%$2.50CS Estimate$2.42$2.49SS Inpatient AdmissionsActualCS EstimateVariance from CSe (bps)SS Adjusted AdmissionsActualCS EstimateVariance from CSe (bps)2.1%1.0%

17、1105.2%2.0%3202.6%1.5%1105.0%2.5%250Source: Company data, Credit Suisse estimates, FactSetNote: EBITDA for UHS reflects total EBITDA including NCI. The consensus estimate may be a combination of estimates showing total EBITDA and estimates showing EBITDA less NCI3Healthcare FacilitiesTHC$4,560 1.2%$

18、4,480$4,519$657 3.6%$653$655$0.56 14.3%$0.44$0.433.3%0.0%3302.2%0.5%170CYH$3,302-7.3%$3,197$3,185$402-2.2%$402$403($0.47) 4600.0% ($0.48)($0.49)2.3%0.0%2301.8%0.0%180Variance from CS Estimate$0.02($0.21)$0.13$0.27Variance from Consensus$0.01($0.26)$0.12$0.26Variance from CS Estimate($1)($69)$2$14Var

19、iance from Consensus$0($102)$4$15Variance from CS Estimate$117($20)$41$49Variance from Consensus$105($20)$80$4812 August 2019Company-by-Company 2Q19 RecapIn the text & figures that follow, we summarize Q2 earnings results for each company.CommuSummaryHealth Systems2Q19 EBITDA was $402 mln (in li

20、ne with CSe/Cons of $403/$402 mln). Q2 net revs were$3.3 bln ($117/105 mln above CSe/Cons). EBITDA margin improved by 70 bps Y/Y to 12.2% (50/40 bps below CSe/Cons). With respect to the FY2020 Medicare IPPS final rule, CYH expects to get an all-in rate increase of around 3% starting Oct 1, 2019 (inc

21、luding 80 bps of benefit from the wage index change).Operating Trends2Q19 SS admits were up 2.3% (vs down 0.1% in 1Q19), while SS adj admits were up 1.8% (vs up 0.8% in 1Q19). SS pricing increased 3.1% Y/Y (vs up 2.3% in 1Q19). SS surgeries were up 3.4% Y/Y (vs up 3.6% in 1Q19), while SS ER visits w

22、ere up 2.4% Y/Y (vs down 1.9% Y/Y in 1Q19). During a brief conversation, management said it was the strongest quarter of admissions growth since prior to 2010. CYH said it has seen sequential improvement in volume trends in part due to its initiatives and due to divesting underperforming facilities.

23、OCF & CAPEX2Q19 OCF was $132 mln, vs a use of cash of $12 mln a yr ago. CapEx was $91 mln vs$125 mln last year. Net Debt to TTM EBITDA remains high 8.5x at 6/30/19. However, the company was in compliance with its first lien net debt to consolidated EBITDA leverage covenant at 4.96x (below the 5.

24、25x covenant ratio) for the twelve months ended June 30, 2019.Figure 2: CYH Debt Maturities as of 6/30/19Source: Company data4Healthcare Facilities12 August 2019Revenue Guidance Raised Slightly Due to Divestiture TimingCYH reiterated its 2019 EBITDA outlook of $1.625-1.725 bln but raised its rev out

25、look by$100 mln to $12.9-13.2 bln. Guidance now assumes SS adj admits grow 0.5-1.5% (vs 0- 1% previously). CYH lowered its OCF outlook by $50 mln from $600-700 mln to $550-650 mln and now expects CapEx of $450-550 mln (vs. $475-575 mln prev).Divestiture ProgramCYH still expects total proceeds of $1.

26、3 bln on its hospital divestiture program ($2.0 bln of revs). Through 6/30/19, the company has collected proceeds of $550 mln as part of this divestiture plan. CYHs remaining divestitures are expected to be higher margin hospitals.Figure 3: CYH Portfolio Rationalization ProgressSource: Company dataH

27、CA HoldingsSummaryHCA posted 2Q19 adjusted EBITDA of $2.29 bln, $69/$102 mln below CSe/Cons. EBITDA margin was 18.2% vs. our estimate of 18.7%. EBITDA growth Y/Y was 3.0%. 2Q19 adjusted EPS was $2.21, $0.21/0.26 below CSe/Cons. HCAs SWB margin and supplies expense margin were both 20 bps higher than

28、 our estimates, driving the lower EBITDA performance relative to our expectations. The effective tax rate was 25.8% vs. our estimate of 23.0%.Pricing and Margin PressureHCA characterized Q2 as slightly below internal expectations as commercial volumes and surgical volumes were weaker than expected,

29、which caused revenue per adj admit to be weak. HCA said that surgical volumes were flat, while medical admissions grew 3%. Medical admissions tend to have longer lengths of stay, and the reimbursement is the5Healthcare Facilities12 August 2019same for a medical patient who is in the hospital for fou

30、r days or five days. However, costs are higher for a patient with a longer length of stay, so that pressured margins.Key Operating StatisticsHCA reported 2Q19 revs of $12.60 bln, up 9.3% Y/Y and $20 mln below both CSe/cons. Same facility equiv admits increased 2.6% (1Q18: 1.8%), while SS inpatient a

31、dmits grew 2.1% (1Q19: 0.9%). SS pricing increased 1.7% Y/Y (1Q19: 3.6% excl settlement award). SS ER visits increased 3.0% Y/Y. SS inpatient surgeries were essentially flat and SS outpatient surgeries were up 0.6% Y/Y.Additional statistics shared by the company include:·····

32、;··Births: down 0.1%NICU admissions or days: up 1.8% (primarily less intense business) Behavioral health: down 0.5%Rehab: up 7.7%Trauma: up 14.7% Observation visits: up 10.7% Urgent care visits: up 7.7%Balance Sheet and Cash FlowHCA has net debt of $33.76 bln and total assets of $45.45 bln

33、. CapEx totaled $964 mln in Q2. OCF was $1.997 bln, up $415 mln Y/Y. HCA repurchased 1.928 mln shares for $242 mln during Q2 and had $1.753 bln remaining authorization at 6/30/19.2019 EBITDA and EPS Guidance Revised HigherDespite Q2 coming in below estimates, the companys overall 1H19 performance ha

34、s been solid, resulting in increased guidance for the year. HCA expects revenues of $50.5-51.5 bln (unchanged), EBITDA of $9.60-9.85 bln (prev $9.45-9.85 bln), and EPS of$10.25-10.65 (prev $9.80-10.40).During Q2, acquisitions contributed roughly 5% to EBITDA growth (up from 3% in Q1), while there wa

35、s a core EBITDA decline of roughly 2%. However, Q1 was strong, so the company is still in a good position relative to full year expectations when taking the first half of the year as a whole. HCA said it is aware of the issues in Q2 and is managing those every day. HCA has plans in place on the reve

36、nue side and the cost side to achieve its targets in 2H19. One of the reasons HCA is confident about its positioning for the back half of the year is because it recently got feedback through its mid-year budget review with its business leaders.6Healthcare Facilities12 August 2019Figure 4: HCA EBITDA

37、 Walk-forward to Full Year 2019OK Hospitals Sale, 2/1/18($15)Malpractice - Favorable Adjustment (Q3)($70)Hurricane Michael Impact (Q4)$312018 Baseline EBITDA Estimate$8,946Mission Health Acquisition (closed 2/1/19)$98Core EBITDA Growth $470 % Reported EBITDA Growth8.4%Source: Company data, Credit Su

38、isse estimatesPrice Transparency and the OPPS Proposed RuleWhile HCA limited its comments on proposed regulations, the OPPS/ASC proposed rule was seen as slightly better than expectations. Regarding price transparency, HCA already makes efforts to provide financial information to patients so they ca

39、n make informed decisions. In relation to public posting of negotiated rates, HCA says that it would need to see a lot more information on this proposal.Tenet HealthcareSummaryTHC reported 2Q19 EBITDA of $657 mln, $3.6/2.2 mln above Cons/CSe. 2Q19 revs were$4.56 bln, $80/42 mln above Cons/CSe. Adjus

40、ted EBITDA margin was 14.4% (20/10 bps below consensus/CSe). Adj EPS was $0.56, above Cons/CSe by $0.12/0.13. The top-line beat was driven by positive hospital revenue growth (2.5% total growth, or $40 mln above our estimate), while Conifers margins outperformed our expectations.Results by SegmentHo

41、spital EBITDA was $347 mln ($1.9 mln below CSe). SS admits grew 3.3% (vs down 0.1% in Q1), while SS adj admits increased 2.2% (vs up 0.6% in Q1). SS pricing was up 3.4% Y/Y (vs up 1.3% in Q1). Amb Care EBITDA was $207 mln ($6.8 mln below CSe), while Conifer EBITDA was $103 mln ($10.9 mln ahead of CS

42、e). During a conversation, management noted that Conifer results included $13 mln of performance revenue. Management also pointed out that it absorbed $13 mln of incremental insurance accruals due to the changing interest rates in the quarter. The company attributed the hospital volume strength more

43、 to company initiatives than to underlying strength in the marketplace.Ambulatory Segment ResultsSame-facility system-wide revs grew 5.3% in 2Q19. Cases grew 3.2% on a same-facility system-wide basis, and SS revenue per case increased 2.0%. In the surgical business, which represents the majority of

44、the revenue in the segment, same-facility system-wide revenue grew 5.2%. Surgery cases were up 2.6% and SS revenue per case was up 2.5%. In the non-surgical business, same-facility system-wide revenue grew 8.0%. SS non- surgery revenue per visit increased 3.6%, while non-surgical visits were up 4.2%

45、.7Healthcare Facilities% Core EBITDA Growth5.2%2019 EBITDA Estimate$9,700Settlement Award with Payor$86Growth on Baseline from 2017/2018 Acquisitions$100Hurricane Harvey Insurance Recovery (Q4) ($49) Hurricane Florence Impact (Q3)$9EBITDA Drag Related to 2017/2018 M&A$91Reported 2018 EBITDA$8,94

46、912 August 2019Cash FlowOperating cash flow was $284 mln in Q2 (vs $348 mln in 2Q18) and adj FCF was $191 mln. The company maintained its full year adj FCF outlook of $600-800 mln, and management said they still anticipate that they will achieve those expectations, as the second half of the year is

47、typically stronger than the first half of the year (e.g., working capital requirements).3Q19 and 2019 Guidance3Q19 guide is in-line. Revenue is expected at $4.3-4.6 bln (Cons: $4.427 bln) and EBITDA at $600-650 mln (Cons: $613 mln). We note that a few estimates (including ours) excluded CA Provider

48、Fee revenue ($65 mln) from Q3, but the company has included it in Q3 guidance as it believes it will be able to recognize the revenue in time.THC maintained its full year guidance, which includes revenue of $18.0-18.4 bln, EBITDA of $2.65-2.75 bln, and EPS of $2.08-2.59.Key assumptions included in 2

49、019 guidance include same-site system wide revenue growth of 4-6% at USPI and $150-175 mln of spending on acquisitions and de novos.THC expects roughly $260 mln of revenue related to the California Provider Fee program.Guidance includes the companys $200 mln cost reduction initiative, with $50 mln r

50、ealized in 2019. The company expects to reach the full $200 mln run rate of savings by the end of 2019. This is in addition to the existing $250 mln cost reduction initiative, which resulted in$250 mln of run rate savings by the end of 2018. The full realized cost savings the company expects in 2019

51、 (incremental to 2018) from these two programs is $105 mln.Hospitals divested to date (including three Chicago-area hospitals divested at the end of January) are expected to impact 2019 EBITDA positively by $31 mln relative to 2018. The Aspen divestiture is expected to have a negative Y/Y impact of

52、$16 mln. Conifer EBITDA is expected to be impacted negatively on a Y/Y basis from Tenet and other client hospital divestitures ($40 mln) and from customer termination fee revenue ($17 mln).The figure below highlights the companys 2019 EBITDA outlook by segment.Figure 5: EBITDA Outlook by SegmentSour

53、ce: Company data8Healthcare Facilities12 August 2019Universal Health ServicesSummaryUHS reported 2Q19 adj EBITDA (net of NCI) growth of 8.2% to $474.8 mln (ahead of CSe by $459.5 mln). Adj EPS grew 11.7% Y/Y to $2.76 ($0.27/$0.26 ahead of CSe/Cons). Excl$0.06 gain oninvestment and $0.04 benefit from

54、 a state tax true-up, EPS wouldhave been $2.66, still ahead of Street ests. In a brief conversation, UHS said surgical case volumes grew 3% during the quarter, bouncing back from the relatively flat surgical volumes in Q1. Management said that taking the entire first half of the year as a whole, the

55、 company is about where it would have expected to be going into 2H19. Thus, UHS is maintaining its full year 2019 guidance.Acute Pricing Rebounds in Q2SS acute revs increased 9.0% Y/Y in 2Q19 (vs up 4.7% in Q1). SS admits were up 5.2% in 2Q19 (same as Q1). SS adj patient days were up 0.3% Y/Y in 2Q1

56、9 (vs up 0.9% in Q1). SS adj admits were up 5.0% (vs up 4.9% in Q1). SS rev/adj admit in 2Q19 was up 3.5% Y/Y (vs down 0.4% in Q1). Q2 SS Acute EBITDA increased 17.0% Y/Y (vs down 2.9% Y/Y in Q1). The acute segment performance improved sequentially due to a more normalized mix of surgical vs. medica

57、l cases. UHS saw strength in Henderson (Las Vegas area) and mentioned that southwest TX (McAllen) had its best quarter in some time.Psych LOS Flat, Volumes Relatively WeakSS psych revs were up 2.7% Y/Y (vs up 3.0% in Q1). SS adj admits were up 0.5% Y/Y in 2Q19 (vs up 2.9% Y/Y in Q1). SS rev/adj patient days increased 2.4% Y/Y (vs up 2.5% in Q1). Although volumes were only up slightly, length of stay was fairly stable improved (down 0.2% Y/Y vs down 1.9% in Q1). UHS previously said that it assumed LOS decline