HCA Healthcare (HCA) Q4 2024 Earnings Call Transcript

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HCA Healthcare (NYSE: HCA)
Q4 2024 Earnings Call
Jan 24, 2025, 10:00 a.m. ET

Contents:

• Prepared Remarks
• Questions and Answers
• Call Participants

Prepared Remarks:

Operator

Thank you for standing by. My name is Janine, and I will be your conference operator for today. At this time, I would like to welcome everyone to the HCA Healthcare fourth quarter 2024 earnings call. All lines have been placed on mute to prevent any background noise.

After today's presentation, there will be an opportunity to ask questions. [Operator instructions] I will now turn the call over to Frank Morgan, vice president of investor relations. Please go ahead.

Frank Morgan -- Vice President, Investor Relations

Good morning and welcome to everyone on today's call. With me this morning is our CEO, Sam Hazen; and CFO, Mike Marks. Sam and Mike will provide some prepared remarks, and then we'll take questions. Before I turn the call over to Sam, let me remind everyone that should today's call contain any forward-looking statements that are based on management's current expectations, numerous risks, uncertainties, and other factors may cause actual results to differ materially from those that may be expressed today.

More information on forward-looking statements and these factors are listed in today's press release and in our various SEC filings. On this morning's call, we may reference measures such as adjusted EBITDA, which is a non-GAAP financial measure. A table providing supplemental information on adjusted EBITDA and reconciling net income attributable to HCA Healthcare Inc. is included in today's release.

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This morning's call is being recorded, and a replay of the call will be available later today. With that, I'll now turn the call over to Sam.

Samuel N. Hazen -- Chief Executive Officer and Director

All right. Thank you, Frank, and good morning to everybody. The company finished the year with strong business fundamentals that were consistent with the previous quarters this year. Demand for healthcare services remained strong, operations were in good order and stable, and the company continued to see favorable investment opportunities.

These fundamentals represent a good starting point as we enter 2025. Our teams have done a fantastic job in remediating a number of facilities in North Carolina, Georgia, and [Technical difficulty] Florida that were impacted by the two major hurricanes we experienced a few months ago. All of these facilities, including Mission Hospital in Asheville, where the community's recovery efforts continue; and Largo Hospital in our West Florida division, resumed normal operations in the quarter. As we end 2024, the first half of this decade has been another period of long-term growth for the company.

We have seen operational improvements across key performance indicators, and we have delivered increased value for our shareholders. These accomplishments position us well for the future. I am grateful to our colleagues who made this happen. We believe the HCA way of combining our high-quality local health networks with the capabilities of a national system consistently produces better patient outcomes, drives greater innovation and efficiency, and yields stronger financial results.

While gratified with these accomplishments, we will maintain our pursuit to improve outcomes further for our stakeholders. We believe the strength of our cash flow and balance sheet position us well for investing further in our networks to increase access, expand capacity, and enhance clinical capabilities. They also allow significant investments in our people to improve training while also creating career growth in our company. And finally, this financial strength creates opportunities to deliver value to our shareholders by effectively allocating capital to generate favorable returns.

Diluted earnings per share as adjusted increased 5.4% in the fourth quarter as compared to the prior year. These results included the effects of the two major hurricanes. In the quarter, we estimate the financial impact from increased costs and lost revenue equated to approximately $0.60 per share. This was in line with the estimation we provided on our previous earnings call.

Revenue growth was approximately 6%. Demand, payer mix, and acuity continued to be strong across most service categories and markets. On a same-facilities basis, inpatient admissions and equivalent admissions grew 3%; emergency room visits increased 2.4%; inpatient surgeries were up 2.8%; outpatient surgery cases, while down 1.3%, again due to the strong payer mix and service mix, we had solid revenue growth in this service line; and lastly, rehab, obstetrics, and cardiac procedure volumes continued to be strong. Operating costs were well managed by our teams and remained in line with our expectations.

Before I close, you will see that our earnings guidance for 2025 aligns with the preliminary outlook we provided on our prior call. And with that, I'll turn the call to Mike for details.

Mike Marks -- Chief Financial Officer

Thank you, Sam, and good morning, everyone. I will provide additional comments on the quarter and year and then discuss our 2025 guidance. Regarding the fourth quarter, we are pleased with the results of the quarter, which demonstrates the excellence of our teams in responding to challenges and still producing solid results. As Sam noted, we estimate that the adverse hurricane impact in fourth quarter of 2024 was approximately 200 million, or $0.60 per diluted shares, in line with our expectations.

These estimates do not include any insurance recoveries the company may receive in the future. Considering the hurricane impact, we had good top-line growth. Sam reviewed the volume information for the quarter. Our volume in the quarter was adversely impacted by both the hurricane impact and a depressed respiratory season compared to the fourth quarter of 2023.

Same-facility net revenue per equivalent admissions increased 2.9% over prior year, in line with our expectations. Consistent with our trends all year, payer mix remained strong in the fourth quarter of 2024, with same-facility managed care admissions up 9.2% compared to the prior-year quarter. While our operations performed well in the quarter, adjusted EBITDA margin declined 60 basis points compared to the prior-year quarter. This decline is primarily related to the impact of the hurricanes on our Largo Hospital in Tampa and the North Carolina division, which had a 100-basis-point unfavorable impact on the adjusted EBITDA margin in the quarter.

Additional expenses related to these hurricanes, including repair costs for our Largo Hospital, drove the increase in other operating expenses as a percent of revenue and half of the supply increase. Adjusted EBITDA in the quarter grew 2.6% compared to the prior-year quarter, which reflects the impact of the hurricanes. Diluted earnings per share as adjusted in the fourth quarter grew 5.4% over the prior-year quarter, also reflecting the impact of the hurricanes. Let me briefly highlight our full year results for 2024.

We had strong top-line growth of 8.7%, with revenue per equivalent admission of 3.2% and equivalent admissions growing 4.5%. We posted a 10-basis-point improvement in adjusted EBITDA margin for the year. Adjusted EBITDA increased 9% over prior year, and diluted earnings per share increased 15.5% over the prior year. We estimate that the lost revenue and additional expenses from the hurricanes adversely impacted full year 2024 by $250 million or $0.73 per diluted share.

Our full year incremental net benefit from supplemental payment programs was approximately 400 million, with fourth quarter being the lowest incremental net benefit of the year. This is an increase from the $100 million to $200 million incremental net benefit we expected, largely due to one-time payments and higher-than-expected program payments in a few states. When we consider the $250 million unfavorable hurricane impact, the prior year $145 million payer settlement, and the incremental net Medicaid supplemental program benefit in the year, we are very pleased with the core operating performance of the company in 2024. Moving to capital allocation.

We continue to deploy a balanced strategy of allocating capital for long-term value creation. Cash flow from operations was 2.6 billion in the quarter and 10.5 billion for the year. This represents an 11% increase in operating cash flow in 2024 over prior year, indicative of great work by our operating and administrative teams. Capital expenditures totaled 1.29 billion in the quarter and 4.9 billion in the year.

And we paid 1.7 billion for repurchases of our outstanding shares during the quarter and 6 billion in the year. We paid $165 million in dividends for the quarter and $690 million for the year. Our debt to adjusted EBITDA leverage remains at the low end of our stated guidance range, and we believe we are well-positioned from a balance sheet perspective. As a result, we are lowering our targeted leverage ratio from our current three to four times to 2.75 to 3.75 times.

We believe this new range fits our profile and our anticipated use of leverage as a company, assuming no significant transactions or extraordinary events. So, with that, let me speak to our 2025 guidance for a moment. As noted in our guidance this morning, we are providing full year 2025 guidance as follows. We expect revenues to range between 72.8 billion and 75.8 billion.

We expect net income attributable to HCA Healthcare to range between 5.85 billion and 6.29 billion. We expect adjusted EBITDA to range between 14.3 billion and 15.1 billion. We expect diluted earnings per share to range between $24.05 and $25.85. We expect capital spending to be approximately 5 billion to 5.2 billion.

Our guidance assumes a growth in equivalent admissions between 3% and 4% and net revenue per equivalent admission between 2% and 3%. Regarding the effects of the 2024 hurricanes on our earnings guidance for 2025, we expect a year-over-year increase in adjusted EBITDA from the reopening of Largo and a year-over-year decline in the North Carolina division as our current assumptions in this market will have lingering effects of Hurricane Helene throughout much of 2025. The increase at Largo and the decline in North Carolina are expected to offset and are not expected to produce a tailwind for us in 2025. Regarding Medicaid supplemental payment programs, as we've said in the past, these programs are complex, variable in timing, and do not fully cover our costs to treat Medicaid patients.

Based on current assumptions, when we aggregate the impact of all of our supplemental payment programs, our guidance contemplate the net effect of Medicaid supplemental payment programs to range from being flat to 2024 to a $250 million headwind, driven by one-time payments received in a few states in 2024. The new Tennessee program is considered in this range. We expect full year margins to be consistent with 2024 and cash flow from operations to range from 10.75 billion to 11.25 billion. As noted in our release this morning, our board of directors has authorized a new $10 billion share repurchase program, and we anticipate completing a significant portion in 2025, subject to market conditions and other factors.

In addition, our board declared an increase in our quarterly dividend from $0.66 to $0.72 per share. And with that, I will turn the call over to Frank for questions.

Frank Morgan -- Vice President, Investor Relations

Thank you, Mike. As a reminder, please limit yourself to one question so that we might give as many as possible in the queue an opportunity to ask a question. Janine, you may now give instruction to those who would like to ask a question.

Questions & Answers:

Operator

Thank you. Ladies and gentlemen, we will now begin the question-and-answer session. [Operator instructions] Our first question comes from the line of Pito Chickering from Deutsche Bank. Please go ahead.

Pito Chickering -- Analyst

Hey. Good morning, guys, and thanks for taking my questions. I guess this question will be on Medicaid supplemental, and I just want to understand a little bit on where we were in -- for 2024, it has been bouncing around a little bit. From third quarter to fourth quarter, did that number change? Was that 400 million that you came in on the year? I guess you sort of bridge where you were on the last time you guided us into where it is now.

And then for 2025, you just sort of, you know, make sure that we bridge sort of where we are in 2024 to 2025 on what's in the low end and high end of guidance for Medicaid supplemental payments. Thank you.

Mike Marks -- Chief Financial Officer

Hey, Pito. This is Mike. Yeah, so if you think about the net incremental benefit from our supplemental payment programs, for the full year 2024, it's about $400 million. As I noted in my comments, fourth quarter was the lowest incremental net benefit of the four quarters in the year.

You may recall from our second quarter that the second quarter of '24 was the highest benefit at 125 million. And so, that's kind of how it spread out. The driver is really largely related to one-time payments that came in in a few states and a couple of our state programs that came in a little more favorably than we expected. So, that's where we landed.

And then, you know, as you start thinking about 2025, as I noted in my guidance, you know, when we consider the -- all the various programs, noting the complexity and the variability and the moving parts, we are projecting and estimating that our net effect of supplemental payment programs will range between flat to 2024 to upwards of a $250 million headwind. That is inclusive of, you know, a pretty wide range of estimation related to the new Tennessee program. So, that's how it kind of went through the year, and that's the basis of our projections for '25.

Pito Chickering -- Analyst

So, Mike, actually, just all -- I guess, for 2024, you're saying it's 400 million. The highest in 2Q is 125 and the lowest in 4Q. I guess can you just actually give us just a quarterly benefit because, you know, 400 million with 2Q 125, that seems it's not that high versus, you know, the rest of the quarter? So, any color on sort of how that flows through the whole year? Thank you.

Mike Marks -- Chief Financial Officer

Well, I mean, I think you can take Q2, Pito, at 125 at the high water mark. And then obviously, first and third quarter would be, you know, a little bit higher and fourth quarter would be the lowest. I mean, that's the best I can give you in terms of the flow through the year.

Pito Chickering -- Analyst

Great. Thanks so much.

Operator

Thank you. Our next question comes from the line of A.J. Rice from UBS. Please go ahead.

A.J. Rice -- UBS -- Analyst

Hi, everybody. It sounds like the MA, managed -- or managed care, rather, same-store admissions were strong. I wonder, because there was so much publicity in the quarter around MCOs, did you -- where are you at in your pricing for '25, '26? Any -- anything new or different you're seeing in terms of utilization review, denial rates, anything along those lines?

Mike Marks -- Chief Financial Officer

So, hi, A.J. This is Mike. In terms of our contracting, we are 80% contracted for '25, 60% contracted for '26, and I think it's 20% contracted for '27. We're still, you know, in -- on top of our range estimates, our targets in terms of pricing.

And as I think about denials and underpayments, you know, clearly, a lot of activity, but we've put a lot of effort over the last couple two or three years and really beefing up our capabilities and managing through the denial and underpayment process. I would say when we think about not only fourth quarter but the full year of '24, we are not seeing the growth in denials being a material impact for the company at this point.

A.J. Rice -- UBS -- Analyst

OK. Thanks.

Operator

Thank you. Our next question comes from the line of Whit Mayo from Leerink Partners. Please go ahead.

Whit Mayo -- Analyst

Hey. Thanks. Good morning. I just wanted to hear maybe some of the internal initiatives that may be moving to the forefront this year.

I feel like you guys have been talking a lot about throughput, ER optimization for a while, case mix, length of stay, all that. Anything on the back end with discharge management, anything around length of stay and bottlenecks that you might be seeing around post-acute? Thanks.

Mike Marks -- Chief Financial Officer

So, yeah, the case management inpatient throughput has been a really strong initiative for us over the last couple of years. We even mentioned it in the Investor Day conference last year. And our work continues and continues to strengthen. You know, specifically, when I think about the going forward into 2025, we have a number of initiatives within our case management infrastructure focused on improving the post-acute care placement and discharge process.

And I might say even especially with our Medicare Advantage payers. And that work continues, and it's important. But if I kind of take stock of where we are today, you know, our length of stay performance in the year has been solid, and we are -- we're forecasting another good year for length of stay management as we head into 2025.

Samuel N. Hazen -- Chief Executive Officer and Director

Yeah. And let me add to that, Mike. So, I mean, we have a number of initiatives that are, you know, progressing across the company. And when you think about our network development initiatives, we continue to add facilities.

You'll see that we've got more facilities at the end of this year than we did last year. So, our capital, as well as some incremental acquisitions in some key markets, is allowing us to expand the reach of our networks. That's showcasing itself in growing market share. What we're seeing in our market share data is really encouraging and lends itself to, you know, sort of continued opportunities in that particular initiative.

In addition to the case management operational initiative that Mike was talking about, we've had tremendous success with our emergency room operational improvement plan as well, and that's yielded throughput improvements, patient satisfaction improvements, and growth, allowing us, again, to extend the reach of that channel and meet the needs of the community in an effective way. And again, as we push into 2025, we'll see more emergency room bed supply inside of our networks as a result of the investments that we're making and then the ability to use those beds productively with our ER revitalization program. We're carrying the elements of success from that program to our operating rooms. We have an operating room optimization initiative that we think is going to be very beneficial to our surgeons and also our patients, and it mirrors a lot of the efforts and the progress we've seen with our emergency room.

And this involves, you know, turnaround time, staffing, other elements of OR, efficiency that's important to our physician partners, as well as our patients. And then finally, I will say that our labor agenda continues to improve. This past year, I'm really proud of our accomplishments as a company. Our employee engagement broadly across all colleagues and especially inside of nursing is at an all-time high for the company.

That has allowed us to reduce turnover and really improve the capabilities of our facilities with having continuity in staffing, a more competent workforce, and the necessary capacity to really meet the demand. So, we have a number of what I call winning plays that are beneficial to the organization, responsive to the communities, and really position our company for success. As we push forward, we've talked about our longer-term initiatives. Our longer-term initiatives are geared toward technology and using technology.

We're on our journey. We're already seeing early signs of success with how AI can improve aspects of our organization administratively, operationally inside of our facilities, and we think clinically as well. So, that's a very exciting agenda. And I know others speak of AI.

But within the processes that exist for us as a healthcare provider, we see a lot of potential to drive better quality, greater efficiencies, and even better management of our business. And so, those things continue. I think our capital allocation is another important initiative of the company. We're investing heavily back in the business.

We'll invest somewhere between 5 billion and 5.2 billion this year. And then we've got the ability to use the cash flow and our balance sheet to deliver even more value through shareholder programs that Mike alluded to earlier. So, all of these combined, we believe to create value: value for our patients, value for our employees, and value for our shareholders.

Whit Mayo -- Analyst

Thank you.

Operator

Thank you. Our next question comes from the line of Ben Hendrix from RBC Capital Markets. Please go ahead.

Ben Hendrix -- RBC Capital Markets -- Analyst

Great. Thank you very much. After another strong year of state exchange enrollment growth, just wanted to get your thoughts on how you see commercial mix progressing and how enrollment fared for you guys. In your opinion, how it's going to impact Florida and Texas? And then any thoughts broadly on the fate of the enhanced subsidies under the new administration? Any efforts you've made with lobbyists or whatever in that regard? Thank you.

Samuel N. Hazen -- Chief Executive Officer and Director

All right. Thanks, Ben. Clearly, the enrollment inside the exchanges continue to strengthen. We think it's somewhere around 25 million at this particular juncture.

So, it's up 12% to 15%, I think, over '24. And we're seeing, you know, consistent growth across a number of HCA states. So, that's a positive. We believe it's a positive outcome for families.

It creates greater access to care. It improves outcomes. So, all of that is a backdrop we think politically is a positive and presents an opportunity for the Trump administration, we believe, to, you know, sustain and ensure that families have coverage, they have affordability, and they have the opportunity to achieve positive outcomes for their -- for themselves and really for their family. So, we don't have any current insights into where this is going.

All we know at this particular juncture is that they are due to expire at the end of next year. We think the backdrop of growth, the backdrop of satisfaction within the enrollments is a positive. And we see opportunities to work with the Trump administration to find a pathway forward to continue what's been a very positive community benefit, we believe, with the exchanges. We have a very robust agenda to partner with other organizations to work within our coalition to support advocacy here, to achieve the outcome that we think makes sense for the different communities that we serve.

So, it's too early for us to call anything on that, but we are active in the process, as you would expect.

Mike Marks -- Chief Financial Officer

And then in terms of your question about payer mix and where it landed, healthcare exchanges now represent 7.5% of our equivalent admissions in 2024 and about 9% of our revenues.

Ben Hendrix -- RBC Capital Markets -- Analyst

Thank you very much.

Operator

Thank you. Our next question comes from the line of Ann Hynes from Mizuho Securities. Please go ahead.

Ann Hynes -- Analyst

Great. Thank you. I just want to ask about the Medicare Two-Midnight rule. How much impact do you think that had on inpatient admissions in 2024, and do you think it will continue to be a benefit? I think last earnings call, you gave a stat that detailed the difference between Medicare Advantage observation versus traditional Medicare fee-for-service.

Can you remind us of what that stat is, and do you think, over time, you can close that gap? That'd be great. Thank you.

Mike Marks -- Chief Financial Officer

Hey. This is Mike. So, in terms of the impact, if I look at, you know, kind of the movement from observation to inpatient status, consistent with the Medicare Advantage Two-Midnight rule, for the full year 2024, you know, we estimate that it was equivalent to approximately 50 basis points of our overall admission growth. I would say that that's remained pretty consistent over the four quarters.

So, you know, I don't think that it's going to be -- you know, you'll see much more movement as you go, you know, into 2025. As to the comparison of Medicare Advantage observation mix to traditional, I would note that, you know, the Medicare Advantage observation as a percentage of total to obs to in is approximately 20% higher than traditional Medicare. But I don't suspect at this rate that we're going to see material changes. You know, at this point, we're really focused on collecting on that revenue and working through the denial and appeal processes associated with the Medicare Advantage program.

I don't think you'll see a material change in kind of the volume trends that we've seen so far this year as we head to '25.

Operator

Thank you. Our next question comes from the line of Andrew Mok from Barclays. Please go ahead.

Andrew Mok -- Barclays -- Analyst

Hi. Good morning. Hoping you could spike out the performance of Mission Hospital in the quarter and help us understand what impact that had on same-store volumes in the quarter and the pace of recovery throughout 2025, including any explicit EBITDA assumptions around hurricanes in the guidance. Thanks.

Mike Marks -- Chief Financial Officer

Let me just talk about volumes overall, Andrew. As we think about fourth quarter, you know, it's 3% same-facility admission and equivalent admission growth to prior year in the quarter. First thing I might mention is it was a little bit of a tougher comparison to fourth quarter of '23, which had strong growth. We did experience -- I mentioned this overall.

And again, I'm speaking overall, not just related to North Carolina division. But overall, we did experience a depressed respiratory season in fourth quarter of '24 compared to fourth quarter of '23. You know, our estimates is that this depressed respiratory season had about a 1-point drag on same-facility admission growth to prior year and about a 2-point drag on same-facility emergency room visits growth to prior year. You know, overall, as a company, the hurricanes as well had an impact on volume growth, primarily in October, but for the whole quarter.

Our estimates are somewhere between 20 basis points and 40 basis points of drag on volume in the quarter related to hurricanes. You know, it's -- that's directly attributable -- you know, I'd also mentioned that, you know, in the month of October, if you look at the rest of the state of Florida, there was clearly some lingering effects as they kind of recover. And then we saw good recovery in November and December. So, you know, that's kind of a tale of the tape on volume in the quarter.

Andrew Mok -- Barclays -- Analyst

And was there any explicit EBITDA assumption for hurricanes in the guidance?

Mike Marks -- Chief Financial Officer

Yeah. So, if you go back to my comments, Andrew, you know, the way that we are guiding for hurricane impact into 2025 is this, that, you know, if you think about -- let's start with Largo, if you think about the Largo Hospital. You know, we do expect a year-over-year increase in adjusted EBITDA from the reopening of Largo and a year-over-year decline in the North Carolina division as our current assumption is that this market will have lingering effects of the hurricane throughout much of 2025. The guidance really contemplates that the increase at Largo and the decline at North Carolina are expected to offset and are not expected to produce a tailwind for us in 2025.

So, that's the way to think about, you know, the hurricanes and their impact into 2025.

Andrew Mok -- Barclays -- Analyst

Great. Thank you.

Operator

Thank you. Our next question comes from the line of Joanna Gajuk from Bank of America. Please go ahead.

Joanna Gajuk -- Analyst

Hi. Good morning. Thank you for taking the question. So, I guess on the somewhat related question, I guess, on the cost side of things.

So, thanks for the color on the impact from the hurricane in the quarter, in Q4, to the other opex line. So, I want to ask about professional fees. You've been talking about this for quite some time, but, you know, most recently, you highlighted the higher-than-expected professional fees to continue into '25. So, can you talk about what you're seeing there, what you assume in your guidance? We heard maybe radiologists are the next group of doctors that are asking for higher fees.

So, is that what you're seeing? And also, can you help us maybe also size that line in your other opex line? Thank you.

Mike Marks -- Chief Financial Officer

So, professional fees are about 24% of other operating expenses. So, that's how you would size it. You know, as we've mentioned in the last several calls, our operating teams have continued to work diligently to address the subsidy pressure from the hospital-based physician group component of our business. And as we've noted, as we've gone through the year, we have bent the cost curve on professional fees as we've moved through '24 really due to these efforts.

So, as I think about, you know, the guidance into 2025, I would say it like this. You know, we expect the cost pressures related to physician costs to moderate a bit further in '25, but it's still going to be higher than just normal inflationary cost trends. And that's how you would think about that flow to -- you know, into the next year. Maybe a double-click on radiology, you know, when you're looking at our hospital-based physician categories, clearly the emergency room and the hospital medicine segments have moved more fully through the business challenges that we see in this segment, you know, really especially given the significant work HCA has done with the acquisition and integration of Alaska.

As it relates to radiology, we did see pressure as we've gone through 2024, and we expect that to continue into 2025. But keep in mind that radiology is a much lower portion of our hospital-based physician subsidies. You know, I'll just finish with this, is that our teams have focused efforts between both our operating teams and our physician management teams, focused on addressing radiology, and we do not expect it to be a material impact in '25.

Joanna Gajuk -- Analyst

Thank you.

Operator

Thank you. Our next question comes from the line of Matthew Gillmor from KeyBanc. Please go ahead.

Matthew Gillmor -- Analyst

Hey. Thanks for the question. I wanted to see if there was any commentary around the California wildfires. I know you've got a couple of facilities in the LA area.

But any impact there to call out or is it just not big enough at the consolidated level to make a real difference?

Samuel N. Hazen -- Chief Executive Officer and Director

This is Sam. We had no impact at our Southern California hospitals as a result of the fires. We did have one of our facilities in Ventura County, you know, on notice, so to speak, in the sense that there was the Kenneth Fire I think it was that was in Ventura County. The Palisades fire did not reach through the valley into Ventura County, but we were on high alert and we have fire mitigation tactics in that particular hospital due to its location and so forth.

And we continue to evolve that, just like we do with hurricanes, and making sure that we can protect our patients and protect our colleagues and protect the asset. And we're iterating, if you will, on our plan there to advance it even further. In Riverside, California, there's been some fires in the proximity that have produced some smoke issues in the community, but no issue whatsoever on our facility there. So, you know, we're fortunate.

That's a horrible event, as everybody knows, but we were on the other side of the canyon with our facility in Thousand Oaks.

Matthew Gillmor -- Analyst

Got it. Thank you.

Operator

Thank you. Our next question comes from the line of Brian Tanquilut from Jefferies. Please go ahead.

Meghan Holtz -- Jefferies -- Analyst

Good morning, everyone. This is Meghan Holtz on for Brian. As we think about Q1 EBITDA, are there any moving pieces, including some seasonality or nonrecurring items, that we should be considering? And then just a quick clarifying question on the supplemental payments. You referred to the new Tennessee program.

Does that mean it was approved recently?

Mike Marks -- Chief Financial Officer

Let me handle the second one first. So, in the Tennessee program, we have been notified of approval of a partial year. And so, we have -- we see an approval that would, in effect, cover July 1 of '24 through December 31st of '24. And then they are transitioning that to a calendar year program beginning in '25.

The 2025 calendar year program, which is new, has not been approved. And so, you know, the new administration will be addressing that. So, that's the status of the new Tennessee program. We don't give quarter-by-quarter guidance, so our normal advice is just to follow our historical seasonal trends and we would stick with that.

So, the '25 guidance is for the full year of 2025.

Meghan Holtz -- Jefferies -- Analyst

Thank you.

Operator

Thank you. Our next question comes from the line of Justin Lake from Wolfe Research. Please go ahead.

Unknown speaker -- -- Analyst

Hi. Thanks. It's Anna on for Justin. Have you guys attempted to size the potential impact of site-neutral payments? And if so, does that sort of alter your strategy at all surrounding your outpatient ASC footprint, and can you tell us where also the same-store ASC revenue growth was in the quarter? Thanks.

Mike Marks -- Chief Financial Officer

So, on site-neutral, you know, let's start with just stating the obvious. You know, we're against program implementations that would cut Medicare hospital outpatient reimbursement, nor do we think that -- programmatically, that it makes sense to pay the same rate for a hospital -- and I'll use surgery, but you could use all of our service -- that operates on a 24/7 basis with full capabilities of physicians and staff and equipment. You know, if you compare that, for example, to our surgery centers who generally operate 8:00 to 4:00, Monday through Friday, and do much less complex work, the idea of paying the same rate for those does not seem to make a lot of sense to us. As it relates to sizing the potential impact, we have not seen a bill yet that would give us enough information to estimate a potential impact.

You know, in the past, as you've seen various proposals and discussions around this, there's been a range of procedures being considered for Medicare site-neutral. On one end of the range would be proposals around hospital-based physician clinic, visits, and outpatient infusion facilities. At that end of the range, HCA would not be materially impacted given how we structure our physician clinics. In other draft proposals, you know, we've seen certain outpatient surgical procedures being considered for cuts to hospital outpatient reimbursement.

You know, we would expect that those would have a bit more notable impact to HCA. But, you know, like a lot of these healthcare policy debates that are going through the government right now, we continue to monitor them closely, as I'm sure you do, and we'll be tracking it.

Samuel N. Hazen -- Chief Executive Officer and Director

And, Mike, I don't see that any site-neutral policy per se will force us or cause us to rethink our strategy around building out our outpatient networks. We believe we are finding opportunities to extend the reach of our networks into new communities, again make it more convenient and more efficient for the patient. And then fully integrate that particular facility into the larger hospital-centric health system is part and parcel to our network development strategy. So, I don't see any changes to that as a result of a Medicare site-neutral provision, if one were to be implemented.

Mike Marks -- Chief Financial Officer

And to your question around the growth in ASC revenues, it's about right at 5% to 6% growth over prior year.

Operator

Thank you. Our next question comes from the line of Scott Fidel from Stephens. Please go ahead.

Scott Fidel -- Analyst

Hi. Thanks. Good morning. I wanted to stick on the policy side and was curious just -- and understanding it's clearly still very early, but if you've done any type of preliminary analysis around Trump's tariff proposals and if you think there could be any net effect or economic impact from that? And then also, from some of the recent executive orders that he has already been, you know, tossing out at a brisk rate, you know, as it relates to foreign workers and then -- and immigrants, etc., just curious if you think any of those may have an effect on either the labor or demand environment? Thanks a lot.

Mike Marks -- Chief Financial Officer

On tariffs, our HealthTrust group purchasing organization has been working on tariff mitigation strategies for many years, including, you know, actions like fixed price contracting, supply chain mapping and risk assessments, and a lot of work on sourcing. Many of our key suppliers have been working on de-risking and diversifying their supply chains over the many -- over the last many years, you know, really kind of especially away from China. Like you, we are closely monitoring the announcements on tariffs from the new administration, including which countries are targeted, the rate of tariffs being implemented, and potential tariff exclusions for healthcare-related items. I would note that for 2025, we have about 70% of our supply spend contracted with firm pricing.

As it relates to kind of sizing it, you know, we need more specific information on the details of these tariff policies, as noted, and we're going to going to need that before we can produce additional estimates of impact. On the other related items, you know, we're tracking those carefully, as all of you are. We don't hire undocumented workers, and so, you know, the impact would be more on supply and demand for labor in those skill mixes, and we're tracking it like you are. And -- but no special insight or note that we can give you at this point.

Operator

Thank you. Our next question comes from the line of Sarah James from Cantor Fitzgerald. Please go ahead.

Sarah James -- Analyst

Thank you. I just want to clarify again the bridge on the equivalent admissions going from the 4.5 to the 3 to 4. So, it sounds like you're implying Mission and Largo offset each other explicitly on EBITDA, but sort of implied on volumes. And then we're calculating 27 bps from a nonrepeatable leap year.

And I'm not sure if you're assuming any pull forward of procedures from consumers that may be concerned about expanded subsidies going away, so I'd love to know that. And then just the rest of it, is that just conservatism going back to the mean or is there anything specific exiting 4Q that you saw that led you to be conservative?

Mike Marks -- Chief Financial Officer

So, you know, when I think about our '25 guidance on volume, and so we're, you know, projecting a 3% to 4% growth in equivalent admissions for '25. And as you noted, you know, we ran higher than that through September year to date, call it a 5% growth. And then fourth quarter was a little bit more in line with that at a 3% growth. Although, as I noted on an earlier question, we did see in fourth quarter a bit of impact with depressed flu season -- sorry, respiratory season and a little bit of drag in fourth quarter related to hurricanes.

As I bridge our volume into '25, I mean, I might note a couple of things. You know, one would be -- and probably the big one is just the healthcare exchanges. We had big enrollment growth in 2024. You know, we'll call it 30%.

And we had big volume growth in 2024, you know, 44%, 45% growth in exchange volume in 2024. As we look at enrollment into 2025 on the healthcare exchanges, you know, we're seeing, you know, call it, 13%, 14%, 15% growth in enrollment in our states for 2025. And so, we do expect that, you know, there will be less volume growth in '25 related to healthcare exchanges than we saw in '24, and that's one of the big drivers of the pullback there. I mentioned earlier that we had an admission benefit related to the Medicare Advantage Two-Midnight rule in '24 that I don't think repeats in '25.

And so, you know -- and then the other thing would be the Medicaid redetermination process that was down this year. I think it flattens out next year. So, you know, all in, we're still forecasting what we think to be a strong demand for healthcare services in '25. You know, a 3% to 4% growth is still above our long-term guide of 2% to 3% and feels rational as we think about the balance of 2025 compared to where we landed in '24.

Sarah James -- Analyst

Thank you.

Operator

Our next question comes from the line of Jamie Perse from Goldman Sachs. Please go ahead.

Jamie Perse -- Goldman Sachs -- Analyst

Hey. Thank you. Good morning. Just on M&A, you guys have had a couple of smaller transactions recently.

I wanted to see what you're seeing just in terms of market activity, how you're thinking about the portfolio overall, including adding scale in existing markets or going into new markets, and just the, you know, aggressiveness you guys could show on the deal front in 2025.

Samuel N. Hazen -- Chief Executive Officer and Director

So, our primary growth in capacity is going to be through our capital spending, and I'll call it organic measures where we add bed supply, we add outpatient facilities, as we mentioned. Those are central elements to our network development strategies and have proven to be very successful and have proven to be very productive from a capital return standpoint. We have, as you mentioned, added when we can to our existing networks. We bought outpatient businesses.

We've complemented our hospital networks with rural facilities and surgical facilities and so forth. And that will continue, I think, into 2025. We don't necessarily have any significant items to point to at this particular juncture. However, we do have a new hospital acquisition that we're expecting to close in the first quarter in Manchester, New Hampshire that will add to and round out our New Hampshire network and give us a fairly broader and more productive, we think, overall, southern New Hampshire network.

We're excited about that. But, you know, most of our investments are going to go toward, I'll call it, just organic system development. We'll have to wait and see if the market starts to shift and more inorganic growth opportunities develop. But at this particular point, we're not anticipating anything material.

Jamie Perse -- Goldman Sachs -- Analyst

OK. Thank you.

Operator

Our next question comes from the line of Ryan Langston from TD Cowen. Please go ahead.

Ryan Langston -- TD Cowen -- Analyst

Hi. Thanks. Same-store inpatient surgical growth looked pretty strong in the quarter. Can you maybe just give us a sense on the types of procedures that was driving that? And outpatient surgical again was down.

I think, in the last couple of quarters, you've said that was mostly in the Medicaid and uninsured categories. Maybe I missed it in your commentary, but just wondering if that's still the case. Thank you.

Samuel N. Hazen -- Chief Executive Officer and Director

So, this is Sam. On the inpatient side, we did see very solid growth in the quarter, you know, fairly broad-based. Again, I think our diversified array of service offerings allows us to move through cycles and then also have less risk with the programs that we have. But we saw strong neurosciences.

We saw strong orthopedics. We saw solid general surgery and vascular. So, it was really broad-based on the inpatient side. On the outpatient side, again, it's driven largely by Medicaid declines, which were down 10%.

Our commercial and exchange volumes were up a little over 1%. Self-pay was down. So, that's why we indicated that our revenue growth and our profitability growth within our outpatient surgery category was up, again, in the quarter and for the year because of the mix and the payer mix, and that's added to, you know, more capacity for those type of cases. So, We're not concerned about the outpatient surgery activity in the company when we look underneath the hood.

Operator

Our next question comes from the line of Steve Baxter from Wells Fargo. Please go ahead.

Stephen Baxter -- Wells Fargo Securities -- Analyst

Hi. Thanks for the question. Just trying to understand some of the moving parts in the quarter a little bit better. I mean, it looks like, broadly, you met expectations in the quarter, but the Medicaid supplemental benefit on a full year basis is now, I think, $200 million larger than what you discussed on the third quarter call, and hurricanes, I think, came in at maybe [Technical difficulty] end of the guidance range that you previously provided.

I think what people are trying to square are those moving parts and whether that's the right way to think about it or that's a misinterpretation of how to look at the quarter. Thank you.

Mike Marks -- Chief Financial Officer

Sure. This is Mike. The way I would frame fourth quarter as you kind of think through the moving parts here, the first is we've mentioned would be the hurricane impact, as noted. In terms of the supplemental payment benefits, you know, I think our description of the fourth quarter having the lowest portion of the net benefit in supplemental payments for the year is a kind of a good way to think about that component.

And then, you know, a couple of other things I might mention when you're thinking about our fourth quarter of '24 earnings growth or adjusted EBITDA growth would be, one, that fourth quarter of 2023 was very strong. So, it was a little bit of a tougher comparison in fourth quarter of this year to last year. And then the second thing just to keep in mind, you know, and this is somewhat related to the depressed respiratory season, is that our Mission growth in the quarter was at 3% versus, you know, if you think about a more akin to 5% September year to date of '24. So, those are some thoughts.

I might mention that if you look at that kind of growth rate, it -- we do believe it's consistent from a launching point as we think about the midpoint of our 2025 guidance range as well. So, we're pleased with the quarter and felt like given everything the company was dealing with in the fourth quarter of 2024, it was a good quarter.

Stephen Baxter -- Wells Fargo Securities -- Analyst

Thanks. And just to clarify, is the Tennessee portion of the 2024 payment recognized in the fourth quarter or is that in the 2025 guidance now? Thank you.

Mike Marks -- Chief Financial Officer

Yeah, it was not recognized in fourth quarter of '24. It'll be a '25 event.

Operator

[Technical difficulty] line of Joshua Raskin from Nephron Research. Please go ahead.

Joshua Raskin -- Analyst

Hi. Thanks and good morning. Could you speak a little bit more to the ASC performance in the quarter, maybe more specifics on rate versus volume underneath that 5% to 6% revenue growth that you talked about and then, more broadly, how you think about the opportunity? And I'm specifically interested, are there any markets where you've got significant inpatient, you know, acute care share but maybe not there on the ASC side yet?

Mike Marks -- Chief Financial Officer

So, let's kind of start with the numbers. We're at 124 surgery centers now. In my previous comment, I mentioned that the net revenue was up 5% to 6% in the quarter. The case volumes were down 1% in the quarter.

You know, we feel good about our ambulatory surgery center network. They're an important part of our overall network and the markets we serve, and it'll be -- it'll continue to be, you know, a part of our network development and optimization work as we go through into '25 and beyond as part of that work. Sam, I don't know if you had anything to add.

Samuel N. Hazen -- Chief Executive Officer and Director

Well, I'm sitting here just sort of canvasing across the company and thinking about the number of surgery centers vis-a-vis the number of hospitals that we have, and we do have a few markets for a variety of reasons that don't have, you know, sort of an average number of facilities per hospital. We've talked about, you know, on average, we have roughly 14 outpatient facilities, including ASCs, clinics, urgent care, and so forth per hospital. That's on average we have in some markets because there's no certificate of need and some markets where we can move much more quickly and aggressively to build out our outpatient network. In some markets like in Georgia, where they have restrictive CON, it limits our ability to execute a strategy the same in Virginia and in North Carolina.

So, you have some differences because of those dynamics. Where we have sort of control over our own destiny, if you will, we're fairly consistent with a large outpatient network, including ASCs, per hospital. So, I'm really struggling to point to a particular market where we feel like we're out of position, if you will, in this space. You know, Mike talked about 125 ambulatory surgery centers.

We probably have another 20 or 25 GI centers that we don't even include in our number, and that's part of our larger outpatient network. Those continue to grow incrementally also. So, I think the limitation for us is mostly regulatory, and we have to work our way through that, as you would expect, through that administrative process.

Joshua Raskin -- Analyst

Helpful. Thank you.

Operator

[Technical difficulty] Bernstein. Please go ahead.

Unknown speaker -- -- Analyst

Great. Thanks a lot. Could you talk a little bit about the progress on labor and labor agenda you've been making, in particular, talking to the pace of hirings in, like, nurse and support staff in '24 and what the guidance is or what's implied in '25? Maybe a little commentary on wage inflation. And then if you could just give a little background on what's the total exposure in the supplemental programs these days and what would be the margin on Medicaid without those programs? Obviously, those are essential to kind of get to an appropriate margin level there.

Thanks.

Mike Marks -- Chief Financial Officer

Yeah, let's cover labor first. You know, I think a good way to measure the progress we've been making is kind of looking at our use of premium labor or contract labor. And contract labor continues to improve. It was down 8% or so for the quarter, the prior year.

Our contract labor as a percentage of SWB was down to 4.6%, 4.5% in the quarter. And it really represents, I think, a lot of really good work that our teams have done, both in terms of improving the retention and reducing the turnover rates that we've seen over the last couple of years coming out of the pandemic and a lot of good work on workforce development, including targeted hiring. You know, our workforce development plan is robust. We've talked in the past about that we're continuing to add Galen Colleges of Nurses in our key markets.

We're continuing to see increases in enrollment in Galen. And we have a robust academic medicine plan where we go out and work with other nursing schools really across our markets and where we really large hire our graduate nurses. So, I think overall, the labor agenda has gone and progressed really well. In terms of wages in fourth quarter, the wages were stable, wage inflation was stable.

And our guidance really contemplates -- if you think about our margin guidance, it really contemplates a steady operating environment as we head into 2025, including overall wage inflation being what I think is stable and rational. So, we're in a good spot on labor. On Medicaid, I'll just mention this, that when you take total Medicaid reimbursement, including the effects of supplemental payment programs on Medicaid, we're still short of covering the cost of care around Medicaid. These programs are important, and they're important to the industry, and not just HCA, but the wide range of not-for-profit and public hospitals across America.

So, that's where I'll leave on margins for Medicaid.

Unknown speaker -- -- Analyst

Great. Thanks.

Frank Morgan -- Vice President, Investor Relations

Janine, maybe time for one more. We're right at the top of the hour.

Operator

Thank you. Our next question comes from the line of Ben Rossi from J.P. Morgan. Please go ahead.

Benjamin Rossi -- JPMorgan Chase and Company -- Analyst

Good morning. Thanks for squeezing me in here for one last one. So, through 2025, capex guide at about 5.1 billion. I think, historically, you've weighted this to 50-50 growth between maintenance and growth capex.

Just with the hurricane recovery, is there any shift in this prioritization in the near term or is 50-50 still a fair consideration for 2025?

Samuel N. Hazen -- Chief Executive Officer and Director

I think that's a fair number. The hurricane is not changing our capital spending. The dynamics in North Carolina really weren't around physical plant destruction. It was community destruction.

Our hospitals mostly were on higher levels than the community as a whole. So, we didn't experience it. In Largo, where we dealt with that, that was mostly repair costs, as Mike mentioned in his commentary. So, our capital spending is really consistent, and it's geared toward our network development.

It's geared toward making sure we have the clinical capabilities and the environment necessary to deliver high-quality care. So, that will continue.

Benjamin Rossi -- JPMorgan Chase and Company -- Analyst

Got it. Thank you.

Samuel N. Hazen -- Chief Executive Officer and Director

Thank you.

Frank Morgan -- Vice President, Investor Relations

OK, Janine.

Operator

That concludes our Q&A session. I'd now like to turn the call over back to Frank Morgan for closing remarks.

Frank Morgan -- Vice President, Investor Relations

Janine, thanks for your help today, and thanks to everyone for joining the call. We hope you have a good weekend. We're around this afternoon. We can answer any additional questions.

Thank you.

Operator

[Operator signoff]

Duration: 0 minutes

Call participants:

Frank Morgan -- Vice President, Investor Relations

Samuel N. Hazen -- Chief Executive Officer and Director

Mike Marks -- Chief Financial Officer

Pito Chickering -- Analyst

A.J. Rice -- UBS -- Analyst

Whit Mayo -- Analyst

Sam Hazen -- Chief Executive Officer and Director

Ben Hendrix -- RBC Capital Markets -- Analyst

Ann Hynes -- Analyst

Andrew Mok -- Barclays -- Analyst

Joanna Gajuk -- Analyst

Matthew Gillmor -- Analyst

Meghan Holtz -- Jefferies -- Analyst

Unknown speaker -- -- Analyst

Scott Fidel -- Analyst

Sarah James -- Analyst

Jamie Perse -- Goldman Sachs -- Analyst

Ryan Langston -- TD Cowen -- Analyst

Stephen Baxter -- Wells Fargo Securities -- Analyst

Joshua Raskin -- Analyst

Josh Raskin -- Analyst

Benjamin Rossi -- JPMorgan Chase and Company -- Analyst

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