コミュニティ・ヘルス・システムズ（CYH）2026年第3四半期決算説明会：EBITDAと業績予想を引き下げ

主なポイント

• コミュニティ・ヘルス・システムズが発表した2026年第3四半期の調整後EBITDAは2億8,000万ドルとなり、マージンは前年同期の12.2%から10.2%へ低下した。事業売却および前四半期以前の調整項目を除くコア調整後EBITDAは約7%減少した。
• 既存施設の純売上高は3.8%増加し、2.2%の入院患者数増加と3.6%の調整後入院患者数増加が寄与した。しかし、調整後入院患者数の伸びのほぼ半分は無保険患者によるものであった。
• 民間保険適用の選択的手術需要は引き続き低調だった。既存施設の手術件数は2%増加したものの、構成比は利益率の高い選択的な整形外科・一般外科手術ではなく、利益率の低い心臓および消化器系の手術に傾斜した。
• 経営陣は2026年通期の業績予想を引き下げ、純売上高を113億〜115億ドル、調整後EBITDAを12億2,500万〜12億7,500万ドルとした。EBITDAの中央値は6.5%引き下げられた。
• 第3四半期の調整後営業キャッシュフローは1億6,800万ドルとなった。通期の営業キャッシュフロー予想は、主にEBITDA減少を背景に1億〜3億ドルへと引き下げられた。
• 同社は外来施設、医師採用、臨床能力への投資を維持する一方で、年間1億ドル以上のコスト削減を見込む各種施策を実施した。

主要財務データ

事業・営業業績

コミュニティ・ヘルス・システムズによると、患者需要は収益性の低めな診療形態や支払者区分へと集中を強めている。既存施設の調整後入院患者数の増加分のうちほぼ半分を無保険患者が占め、救急部門受診数の伸びの実質的にすべてが無保険患者によるものとなった。

経営陣は、自己負担金（コペイ）や免責金額（デダクタブル）の上昇、および広範な家計のコスト圧力を、選択的手術需要の低迷要因に挙げた。クリニック受診数は7.9%増加し、整形外科のMRIやその他の画像診断件数も好調を維持した。同社はこれらの指標について、手術が競合他社に奪われたのではなく延期されている証拠と捉えているが、需要がいつ回復するかについて明確な時期は示さなかった。

手術件数は前年同期比で増加に転じ、既存施設ベースで2%増加した。入院手術が減少した一方、外来手術は増加した。心臓および消化器系の処置は拡大したものの、高額な医療機器コストにより、TAVRやWatchmanといった処置は、延期されている選択的な整形外科・一般外科手術に比べて利益率が低くなった。

人員動向は改善した。医師の離職率は40%以上低下し、病棟正看護師の離職率は10%低下した。また、雇用医療従事者数は前年同期比で2.5%増加した。経営陣は、これらの傾向が今後の手術対応能力と患者紹介の増加を後押しすると説明した。

同社はまた、9月に外来クリニックおよび救急部門でのアンビエント・リスニング（自動音声記録技術）の導入件数が100万件を突破したと発表した。経営陣によると、この技術により事務負担が軽減されるとともに、請求の正確性、コーディングの精度、および臨床医の生産性が向上しているという。

コスト管理は引き続き人件費、調達、テクノロジー、および組織再編に焦点が当てられた。すでに実施された施策により、年間1億ドル以上の削減効果が見込まれており、資材やサービス契約の更新に伴い、さらなる削減機会が期待されている。

業績予想（ガイダンス）

経営陣は、通期予想を達成するために第4四半期の営業キャッシュフローを8,500万〜1億8,500万ドルと見込んでいる。設備投資の約半分は成長プロジェクトに向けられているが、同社は2027年に向けて一定の柔軟性を維持している。

コミュニティ・ヘルス・システムズは、地方ヘルスケア変革プログラムの1年目の交付金として2,500万〜3,000万ドルを見込んでおり、主として設備投資やソフトウェアのアップグレードに充てる。関連する資金および支出の大部分は2027年に発生する見込みで、収益は同年度以降、複数期間にわたって認識される。

2027年に向けて、経営陣は民間保険料率の改定、メディケア（高齢者公的医療保険）の入院・外来に関する改定案、外来事業の拡大、および延期された手術の回復可能性を潜在的な支援要因として挙げた。一方で、2026年に計上された1,500万〜2,000万ドルの前年度州主導給付金（State-Directed Payments）の恩恵は再発生しないと警戒を促した。

リスクおよび注視すべき点

• HICS（医療保険交換所制度）の脱退および自己負担への移行による通期の影響試算は、8,000万〜9,000万ドルに拡大した。第3四半期の影響額は3,000万〜3,500万ドルであり、経営陣は第4四半期に約2,500万〜3,000万ドルを見込んでいる。
• 無保険患者の受診が増加する中、自己負担分の回収額は減少が続いた。経営陣は収益認識の見積もりを毎四半期更新しており、現時点で一括調整が発生するとは予想していないと説明した。
• 専門診療科経費は、主に麻酔科と放射線科の影響で13%増加した。経営陣は、この費目が2027年もインフレ率を超えるペースで拡大し続けると予想している。
• 支払者による保険請求の審査・処理の遅れが続いている。第3四半期中に状況が悪化することはなく、売上債権回収日数は6月30日から9月30日にかけて安定していた。
• メディケイドの就労要件化や医療提供者税の財源削減の可能性は緩やかな逆風となり得るが、経営陣はその影響は依然として不透明であるとしている。
• マクロ経済の圧力や患者の動向を巡る不確実性により、経営陣は中期目標を再評価している。

アナリスト質疑応答の要点

延期された選択的手術：経営陣によると、自己負担金や免責金額が高額な民間保険の加入患者が、治療を延期している主な層である。公的保険の加入患者では同様の延期は見られない。同社は分割払いなどの条件を提供しているが、保険会社との契約上、原則として自己負担金や免責金額を免除することはできない。

2027年の業績牽引要因：潜在的な追い風には、民間保険の価格改定、メディケアの報酬改定、外来事業の拡大、医師採用、および延期されていた治療の回復が含まれる。逆風には、継続的な無保険患者の増加圧力、メディケイドの補償範囲に関する不確実性、一括計上された州主導給付金の剥落、および高水準な専門診療科経費が挙げられる。

外来事業の拡大：コミュニティ・ヘルス・システムズは2026年中に2件の日帰り手術センターを取得し、2件を新規開設した。経営陣はさらなる開発や買収を見込んでいるが、医師との提携体制の構築が資金投下のタイミングに影響を与える可能性がある。

地方ヘルスケア変革プログラム：同社は1年目の申請採択率が約30%であったと報告した。経営陣は2年目のさらなる機会や、CHSの対象地域における地域社会・学術プログラムへ交付される資金からの間接的な恩恵を見込んでいる。

決算説明会 文字起こし全文

決算説明会の完全なトランスクリプト

経営陣による説明

Operator

Good day. And welcome to the Community Health Systems Third Quarter 2026 Earnings Conference Call. [Operator Instructions] Please also note, today's event is being recorded. I would now like to turn the conference over to Anton High, Vice President of Investor Relations. Please go ahead.

Unknown Speaker

Thank you, Rocco. Good morning and welcome to Community Health Systems Third Quarter 2026 Conference Call. Joining me on today's call are Kevin Hammons, Chief Executive Officer, and Jason Johnson, Executive Vice President and Chief Financial Officer. Before we begin, I must remind everyone that this conference call may contain certain forward-looking statements, including all statements do not relate solely to historical or current facts. These forward-looking statements are subject to a number of known and unknown risks, which are described in headings such as risk factors in our annual report on Form 10-K and other reports filed with or furnished to the SEC. Actual results may differ significantly from those expressed in any forward-looking statements in today's discussion. We do not intend to update any of these forward-looking statements. Yesterday afternoon, we issued a press release with our financial statements and definitions and calculations of adjusted EBITDA and adjusted EPS. We've also posted a supplemental slide presentation on our website. All calculations we discuss today will exclude gains or losses from early extinguishment of debt, impairment gains or losses on the sale of businesses, expense from government and other legal matters and related costs, expense from employee termination benefits and other restructuring charges, and business transformation costs. With that said, I will turn the.

Kevin Hammons

call over to Kevin Hammons, Chief Executive Officer. Thank you, Anton. Good morning, everyone, and thank you for joining our Third Quarter 2026 Conference Call. For your continued interest in CHS. I want to begin by expressing my sincere appreciation to our dedicated clinical and operational teams across all of our facilities. Their steadfast commitment enables us to advance our core vision, making the healthcare experience exceptional for our patients, our communities, and each other. Even with the dynamic operating landscape shaped by shifting coverage dynamics and broader macroeconomic pressures, we are taking direct proactive steps to fortify our competitive position. Our execution remains anchored in our core operational priorities, elevating clinical quality, enhancing the patient physician experience, and strengthening our employee engagement.

Building on the quality momentum we shared last quarter, including strong Leapfrog safety grades across our network, our facilities continue to deliver outstanding clinical outcomes. In the third quarter, we further reduced our severe sepsis and septic shock mortality rates and hospital-acquired infection measures, metrics continuing to outperform national benchmarks. This commitment to clinical excellence is not just an operational milestone; it directly positions CHS as the provider of choice in our communities, creating a distinct competitive advantage that positions us to expand market share as patient demand normalizes and to achieve sustainable growth into the future. To capture that demand and establish clear building blocks for future revenue growth, we are actively expanding our clinical capacity and stabilizing our core workforce. On the talent front, we reduced physician turnover by over 40% and bedside RN turnover by 10% compared to the prior year. This improved physician retention, along with targeted specialist recruiting, has driven a 2.5% year-over-year increase in our employee provider base, expanding our procedural capacity and referral networks to set the stage for higher acuity volume and revenue growth in future quarters.

Simultaneously, our investments in technology are driving operational efficiency and clinician engagement. In September, we surpassed 1 million ambient listening encounters across our outpatient clinics and emergency departments. This technology significantly alleviates administrative burden, reduces provider burnout, and enhances charge capture and coding accuracy, driving productivity improvements while elevating the overall patient experience. Returning to our operating performance, third quarter adjusted EBITDA was $280 million. While overall financial results fell below our internal forecast due to the same factors that many peers are experiencing, namely elevated uninsured volumes and temporary softness in commercial elective procedures, we delivered sequential volume gains and solid cash flow performance. Importantly, our leading indicators clearly demonstrate that care is being deferred rather than lost to competitors. During the quarter, same-store commercial adjusted admissions, excluding exchanges, increased 2.7%, clinic visits surged 7.9% and MRIs and other imaging tests showed solid growth. These metrics confirm that our local networks are capturing available market demand and maintaining strong market share.

To protect profitability in the current environment while elective care defers, we are proactively managing our cost structure. Specifically, already this year we've taken actions to generate over $100 million in projected annual savings and we expect to implement further structural cost reductions in the future. These decisive measures demonstrate our commitment to disciplined margin management today without compromising our clinical capacity or operational readiness for tomorrow. Looking forward, we are positioning CHS to capitalize on several multi-year growth tailwinds. We remain focused on disciplined capital allocation, strategically expanding high return outpatient entry points including ASCs, urgent care centers, free-standing EDs, and targeted physician practices against rigorous financial return targets. Outside initiatives like the Rural Health Transformation Fund present opportunities to expand healthcare access, overcome patient mobility barriers, and drive incremental patient volume into our facilities in future years. In closing, our industry-leading quality performance, expanding physician employment, targeted capital investments and proactive cost management give us high confidence in our path forward. We are actively executing on the leverage within our control to navigate short-term industry dynamics and build long-term sustainable shareholder value. Let me now turn the line over to Jason Johnson to walk through the third quarter financial details in greater depth. Jason?

Jason Johnson

Thank you and good morning everyone. As Kevin noted during his prepared remarks, financial results for the third quarter came in below our internal expectations, despite strong discipline from our operating teams, reflecting continued outside pressures on service and payer mix that are affecting the industry as a whole. Adjusted EBITDA was $280 million with a margin of 10.2% versus 12.2% in the prior year period, when excluding the impact of divestitures and out of period items from prior year results, reflected an approximate 7% core decline year over year. During the quarter, we did not recognize any out-of-period benefits from new or existing state-directed payment programs, and consistent with last quarter, did not recognize any amounts for the 2026 Florida program. Same-store net revenue growth of 3.8% year-over-year included a 2.2% increase in admissions and 3.6% growth in adjusted admissions. As Kevin previously noted, almost half the growth in adjusted admissions came from uninsured patients. And while overall, same-store surgeries increased 2%, similar to many of our peers, demand in commercial elective procedures remained below expectations. This unfavorable payer mix and service mix shift led to a 0.2% growth in same-store net revenue per adjusted admission.

Our operating teams maintain strong cost discipline in this environment, particularly in the areas of labor management and supply chain efficiency. Along with our structural expense management program that's run corporately, we're taking steps to proactively manage profitability in the current environment. Same-store operating expense for adjusted admission increased 2.1%, and when excluding the impact of provider taxes, was up just 1.3%, significantly better than inflation. Same-store supply expense increased 1.6% and was down on a per adjusted admission basis, reflecting ongoing improvement in procurement through our ERP as well as lower mix of surgical revenues. Contract labor spend declined to 1.6% on a same-store basis, and an average hourly rate was up 2.1%, both below our expectations coming into the year. Medical specialties, meanwhile, remained a pain point on the expense side, increasing 13% year over year on the same-store basis, and increased again primarily reflected pressure in anesthesia and radiology. And while it was improved from the 19% increase in the second quarter, it was well above our initial expectations for 5% to 8% growth for the year.

We are pleased to see improvement in cash flows on both a year-over-year and sequential basis. Cash generated from operations for the third quarter of 2026 was $168 million when adjusted to exclude taxes on divestiture gains, up from $121 million in the prior year period, reflecting better management of accounts payable and ongoing collection of accounts receivable, including timing of state-directed payment programs we discussed last quarter. Total net leverage stood at 7.2 times at quarter end, up from 6.6 times at year-end 2025, despite the $810 million reduction in debt year to date, due to the reduction in trailing 12-month adjusted EBITDA. We ended the quarter with no amounts drawn on our ABL and our next significant maturity is in 2029. Based on year-to-date performance and our expectations for the remainder of the year, we are updating our full year 2026 financial outlook. Net revenue is now expected to be $11.3 billion to $11.5 billion. And adjusted EBITDA range is now $1.225 billion to $1.275 billion, or a 6.5% reduction at the midpoint. We've also reduced the cash flow from operations guidance to $100 million to $300 million, primarily reflecting the lower EBITDA. The guidance reflects our updated views of the impact from higher uncompensated care trends as a result of coverage loss and the softness we've observed in commercial elective demand through the end of the year. Finally, our Year 1 awards in the Rural Health Transformation Program are expected to be $25 million to $30 million, primarily related to capital expenditures and software upgrades. We expect to receive most of the grant funds associated with the Year 1 awards and to fund the grant-related expenditures in 2027, with Year 1 awards will be recognized over multiple periods starting in 2027. We plan to actively evaluate and pursue Year 2 funding opportunities as they become available. This concludes our prepared remarks. I'll now hand the call back to the operator to open live for questions.

Operator

Thank you. We will now begin the question and answer session. [Operator Instructions] Today's first question comes from Brian Tanquilut with Jefferies. Please go ahead.

質疑応答

Brian Tanquilut

Hey, good morning, guys. Yeah, so first question, maybe as I think just about the volume performance this quarter, you know, volumes are pretty good, but I think you called out acuity and obviously the payer mix is not as good. So when I think about the higher acuity cases, specifically ortho, what do you think is happening there? On the payer mix side, as we think through the mitigation or some of the offsets that you can push through, Kevin, how are you thinking about this? Because obviously, there's an earnings power reset that has happened here. And how do we think about the ability to grow going forward? Thanks.

Kevin Hammons

Sure, thanks Brian. I'll start off here. So, you know, what we think is happening is certainly the, you know, co-pays and deductibles continue to go up. And with the kind of macroeconomic pressures, I think with higher gas prices, grocery prices, and higher cost of insurance and rent that we've been talking about are just putting pressure on people's ability to pay those co-pays and people are deferring care. As I mentioned, our clinic visits are up 7.9%. We're performing orthopedic MRIs at a rate that outpaces prior year, so we're capturing more of those patients in our system. They need the care, but as we speak to our doctors and they're speaking with their patients, what we're seeing more of is people kind of deferring that ultimate procedure of getting the surgery. So those office visits, those tests are not translating into the higher acuity procedure at the same rate as we have seen in the past.

Again, that gives us confidence that that business is just being deferred. There's pent-up demand. Ultimately we think that it comes back into the system because when you need a joint replacement, it's not going to heal on its own. So, we think that, you know, as we either get into our initial expectations, we got into the back, we would see that seasonality growth. We did not see as much of that in the third quarter as we had previously expected. Now as you get to October, if people have not met their co-pay and deductible, it's likely they could push that off until next year, get their procedures, you know, in the first half of the year and have a longer period of time to have other medical procedures done without having to pay a co-pay and deductible again. So we've adjusted our guidance kind of accordingly to reflect our outlook on that.

Brian Tanquilut

Then maybe my second question, Jason, is I think about the building blocks for 2027. I mean, I know without going to guidance it's a little early, but how should we be thinking about thinking through the 2027 outlook?

Jason Johnson

Yes, you're right. It's a little early for us to give guidance just yet. We're still in forecasting and setting our budgets. I think we can speak broadly to some of the puts and takes as we see them today. And I think this commentary is going to be consistent with what I've seen so far from some of our peers. But maybe for us, starting with some of the more certain items that were out of period and divestiture activities. So for the out of period state-directed payment programs, about $15 million to $20 million net benefit in 2026 that won't repeat in 2027. As you may recall, that includes positive contributions from Florida for the program year 2025 and Georgia, partly offset by some negative prior year true-ups in Indiana and Arizona. Divestiture activity, 2025 divestitures are actually going to be a wash. And then maybe some of the items that are less certain and are still coming into view. First, there should be tailwinds from solid commercial rate updates as well as the Medicare inpatient and outpatient rule as proposed. The outpatient rule is expected in the coming days, I believe. We also think it's reasonable to anticipate some of the deferred elective procedures to return next year, which should contribute to solid volume growth and improvement in payer and service mix versus what we saw last year in 2026, which we view as a characteristically unfavorable mix. The payer and service mix improvements we expect to be further supported by the investments that we've made in outpatient and ASC footprint, including the material acquisition of an ASC we discussed in the second quarter and three other acquisitions or de novo openings this year, as well as the recent physician recruitment activity and improved retention. I mentioned Rural Health Transformation Program, which we think will be a modest positive impact on EBITDA next year. That's the $25 million to $30 million of Year 1 funds, mostly related to capital expenditures and software upgrades, but that income begins to be recognized over a multi-year period starting in 2027.

Maybe for some headwinds, the spike in uninsured volumes from the HICS subsidy really began to ramp up in the second quarter of 2026. So I think it's reasonable to expect another quarter of that, along with some potential future degradation in coverage, depending on the outcome of the 2027 open enrollment, although we think it'll be to a lesser extent in 2026. As regards the Medicaid work requirements, under OBBA, we think there will be a modest headwind there. We have about a little over half of our Medicaid volumes and revenues come from expansion states. We think it's likely that the very large majority will qualify for continued coverage under the various exemptions like age, caregiver status or medical frailty. But we really just don't know exactly what the impact will be until the data starts coming in on how many might drop off, including for technical reasons like failing to provide the documentation. There's also a potential modest headwind in the fourth quarter of 2027 from the OBBA funding cut to provider taxes. And finally, maybe on the cost side, I think we expect to continue to maintain our strong discipline across labor and supplies, including through our corporate-run structural expense management program. The big question mark on cost is the medical specialties, which we expect to continue to grow well above inflation next year.

Operator

Our next question today comes from A.J. Rice at UBS. Please go ahead.

Albert Rice

Hi, everybody. Just for my first question, I was going to ask about the cash flow. I know you did take down the expectation for this year, the full year, but you're still looking for about $100 million to $300 million in positive cash flow. And I think if I got it right through year to date, you're negative $15 million or so. I just wonder about your confidence in being able to get to that positive $100 million to $300 million. And then is the decline in cash flow made you take a look at any of the capital spending targets and maybe push those out or revisit them?

Jason Johnson

Yes, our adjusted, this is Jason, our adjusted cash flow from operations when you exclude the taxes that we paid on divestiture gains is a positive $15 million. So our updated cash flow guidance assumes an $85 million to $185 million cash flow from operations generated in the fourth quarter. That compares to the, you know, prior year was a positive $309 million and the third quarter it was $168 million so I feel good and comfortable that we can achieve. We did not change our capital expenditure guidance and still expect to come in between the range for either the $350 million to $400 million.

Kevin Hammons

Hey, Jason, it's Kevin. Jason's absolutely right. I think we're confident with our updated guidance as we look ahead. About 50% of our capital spending has been on growth projects, and we do have a little bit of flexibility as we look out into 2027 there. But we're continuing to look at opportunities to grow and expand our service footprint and ourselves and get good returns from that capital spending. So, we'll continue to look at it closely and kind of have discipline around that.

Albert Rice

Okay, and for my follow-up, I think you're the first of the public companies to comment on the Rural Transformation Fund and how that's playing out. Maybe can you just sort of walk through how it did play out? Did this end up being about what you expected? Were you hoping for more? Was this a positive surprise? And anything about the way it was processed as we think about future years on that fund?

Jason Johnson

Yes, this is Jason. I'd say if I went back a year ago, I would say that I would be, we expected to receive more than we did for Year 1. However, as we began to kick off the process for evaluating and pursuing, and we actually saw the [guidelines?] for proposing to use the funds, this probably is more in line with what we expected and I was trying to advise caution, and some of the comments I made previously about how beneficial this could be. However, $25 million to $30 million Year 1. I think we submitted a lot of applications and I think it's probably about a 30% success which I understand from talking to others is actually pretty successful. Year 2 and beyond, there's opportunities to, uh, the states didn't have a lot of time to prepare for Year 1, so they're already kicking off Year 2, uh, but I think in the future there's lobbying efforts and making sure that we can begin to align with strategies more than shovel-ready projects, which were a lot of the equipment.

Kevin Hammons

uses that were for this year just due to timing. One other comment I might add to that, and as we are now observing where some of the states are spending the money. There are more social programs run by local communities that are getting a lot of the rural health money. There's also some academic institutions, but we believe this could be a halo effect across. So even though we are not directly receiving some of the rural health transformation money, that money is being directed to many of our communities through other forms to benefit people's healthcare and there may be some halo effect and some reimbursement potential for us or these programs may direct people into getting more care.

Operator

Our next question today comes from Ben Hendricks at RBC. Please go ahead.

Unknown Speaker

Hi, guys. It's Drew Steadman for Ben. Operating expense per adjusted admission excluding provider taxes as well below inflation, what's driving that discipline and how sustainable is that level of cost control heading into 2027?

Jason Johnson

Yes, I think maybe start with the labor and the supplies are our ERP investment and improving processes are a big driver for both of those items. And I think it's sustainable again that headwind. You know, we'd be even a better story if the medical specialties weren't this high this year. On salaries, I guess that also points to the improved retention that Kevin called out in his comments and really the specialties are just going to take a little time because it's a market by market analysis and scenarios depending on the dynamics in each market.

Unknown Speaker

And then just as a follow-up, you flagged interest in urgent care and freestanding EDs and surgery centers as more insulated from payer dynamics. How quickly could you deploy capital into those assets and, you know, what are you seeing valuation-wise in those?

Kevin Hammons

So, we've already been deploying some capital, so in the second quarter, in the second quarter we announced the acquisition of two surgery centers, one of them being the largest multi-specialty surgery center in the state of Alabama. We also built two de novo surgery centers that were opened in the second quarter. We're continuing to pursue some opportunities with acquisition and/or developing new. The big barrier there is typically making sure that we're aligned with the right physician groups in the markets. That is the thing that can probably take the longer period of time in terms of deploying capital is just making sure you have the correct physician alignment. But I would anticipate us continuing to make progress in those ambulatory sites over the course of the remaining year and certainly well into next year and beyond.

Operator

Thank you. And our next question today comes from Stephen Baxter at Wells Fargo. Please go ahead.

Stephen Baxter

Hi, thanks. Um, it looks like the surgical trends, you know actually improved a pretty good deal in the, you know, in the third quarter, had like actually pretty solid growth there. I think like 2% was the same-store number, but you're still kind of talking about a bit of a shortfall in like the acuity and I guess elective procedure environment. I guess, can you talk a little bit about, you know, the type of surgeries that improved and how that's going to affect the future and drove that growth? And I guess, were you expecting more growth or was it just not the right kind of surgical mix inside of that number? Yes.

Kevin Hammons

Yes, it's really, we did bend the trend on surgical procedures. We've had several quarters now where, you know, we've seen negative year-over-year surgical procedures and this quarter we kind of bent the trend and turned that positive to 2%. It really was a mixed issue. Inpatient surgeries were down, outpatient surgeries were up. We saw more cardiac procedures and more GI procedures this quarter. The cardiac procedures, though, particularly like TAVRs and Watchman devices, are low-margin because of the high cost of the devices. Well, what we were short on were the elective orthopedic and elective general surgery type procedures that are higher-margin business, and those are more elective type procedures and that's what's being deferred. Again, kind of fits back into the story of: We believe this is a patient decision around care and being influenced by financial decisions, so it's patient behavior, as well as trying to get out there. We feel very good about the growth and about capturing the business within our markets and that gives us another level of confidence that as these elective procedures come back, they will come back into our system.

Stephen Baxter

Got it. Um and then just wanted to ask for, you know, an update on the latest thinking on the medium-term targets. It looks like maybe that slide from the presentation, you know, isn't there anymore this quarter. I mean, should we think that there's some element of, you know, reassessment given the challenges at the moment and kind of the amount of moving parts in the industry or is that just kind of a streamlining thing and we shouldn't think about it as any change there.

Kevin Hammons

Yeah, I think we're reassessing given the current kind of dynamics in the industry right now. Some of the headwinds causing the macroeconomic issues, if you think about down prices, the disruption in the Middle East have not yet been resolved. As we sat here even a quarter ago, there was more talk in the media that those things would be resolved in the near term, but now we're here in October, they're still not resolved. So I think it makes sense to kind of reassess and pause on those before we have a little more clarity on some of what's impacting people's decision-making and the patient behavior.

Operator

Thank you. And our next question today comes from Jason Cassorla with Guggenheim.

Jason Cassorla

I was hoping to get your thoughts on uninsured utilization activity. Obviously have the patients that are transitioning off exchange coverage that are going uninsured. But are you seeing any changes in the utilization on like a per uninsured individual basis or like any pressures because patients who are newly uninsured are leveraging your inpatient emergency departments for lower acuity services instead of their, you know, PCP or some other setting that they would have otherwise used when they were previously insured. And maybe backstopping all this, can you remind us how you're thinking about bad debt and reserving levels for that as we think about next year? Thanks.

Kevin Hammons

Sure. So, you know, if you look at just numbers, it seems to be about a one-for-one decline in former exchange business versus increase in uninsured business. We think that those uninsured people though are utilizing the system at a higher rate. Certainly utilizing our ERs, substantially all of the growth in ER visits have come from uninsured patients. Across our system and that's pretty even across all locations. I mean, it's widespread, so it's not a geographic phenomenon. And because of not having insurance, they are no longer going to the primary care doctors. They are coming into the hospital ERs for those lower acuity services.

Jason Johnson

And from a revenue recognition standpoint, we do estimate the amount of uncollectible revenue and update our estimates every quarter considering the trends in cash collections, which we have seen collections on the self-pay portion continue to decline. But I think from a perspective, we're not expecting any kind of one-time adjustment in the future from the current.

Kevin Hammons

pay volume increase.

Jason Cassorla

Got it. Okay, very helpful.

Kevin Hammons

Maybe the last bit of color I'd add on that is we look at our clinic visits, though, that were up 7.9%, those are capturing more of the insured business. So as we look at the growth in our clinic visits, we are capturing more of the insured patients, whether it's government insured or commercially insured, in the clinic visits. Okay.

Jason Cassorla

Got it. Okay, very helpful. And if I could follow up, I wanted to go back to your prepared comments. I think you said about $100 million of projected savings. Maybe could you expand on that? How much you've harvested year to date? What the visibility is for savings yet to be realized in 2027 and beyond? And kind of where those buckets, those major buckets of savings are coming from would be very helpful. Thanks.

Kevin Hammons

Sure. I, you know, my intent on our prepared remarks is I would expect that the actions we've taken today have a future benefit of something in that $100 million range plus. We're continuing to work on this program. We've taken steps across several areas in the company, including restructuring some departments, gaining benefits through the use of our ERP and technology through purchased service contracts as we use our ERP and have better visibility into certain spending, the ability to control that, leveraging scale through supply contracting and so forth. So there's a number of areas that we have an organized program around and our dollar amount there was what we would expect kind of at a minimum going forward for the actions already taken, but the work continues on to identify additional opportunities and expand that budget. I think particularly as it relates to supply chain items, many of our contracts don't come up for renewal all at the same time. There's kind of a runway of opportunities going forward for us to be able to capture additional savings on many of these items in the future that we've not yet taken steps on.

Operator

Our next question today comes from Sean Dodge at BMO Capital Markets.

Sean Dodge

Kevin, maybe going back to your comments around the top of the funnel activity you're seeing with things like clinic visits and imaging that all continuing to be healthy, but just not converting as much into elective surgical volumes. What are the tools or levers you have to try and drive better conversion or the things you can do like payment plans, financing options, more patient outreach? Just what can you do there? What are you doing to try and pull more of that through?

Kevin Hammons

We are doing more patient outreach, so I do think it starts there. You know, some of this, if it's really based on patient behavior and financial decisions. We do offer some payment terms on patient responsibility. We are limited in our ability to waive co-pays and deductibles because of, you know, the payer contracts don't allow us to do that. But, you know, that really becomes the decision largely between the patient and their physician in terms of the need for care and when it can be done. Some of this delay, and we don't have complete visibility into it because a number of our physicians are independent physicians as well that practice at our facilities and we capture the surgeries, but insurance can be delaying some of this by requiring additional physical therapy, you know, some delays in pre-authorization, but ultimately we expect, you know, net to come through.

Sean Dodge

Okay. And then just relating to the cash flow, last quarter you all mentioned a slowdown in payments from the payers. I don't think you've commented on it yet, but just any update there? Is kind of this payer behavior dynamic, is that stabilized? Is that worse, gotten better? Just anything there?

Jason Johnson

Hey Sean, this is Jason. It has continued. It hasn't worsened. We continue to see a slowdown in the payment of claims. No worse than it was in the first quarter when we really first started seeing that shock, but it hasn't changed. Either our days in AR are consistent from June 30 to September 30, so we've kind of maintained.

Sean Dodge

Thank you again.

Operator

Thank you. And our final question today comes from Andrew Mok at Barclays. Please go ahead.

Andrew Mok

Appreciate all the color on deferrals and consumer behavior. Do you have any insights into who is deferring these elective procedures within the commercial population, whether by income, job type, or other demographic factor? And to the extent it does come back next year, would you expect those procedures to return relatively evenly throughout next year, or would the recovery be more back-end weighted, given similar deductible dynamics? Thanks.

Kevin Hammons

What we do have is a lot of this deferred care is coming from your commercially insured patients who have the highest co-pays and deductibles. We don't have demographics directly on each of those, again because some of that deferral is coming through independent physicians, so we wouldn't necessarily have captured that information. But we are seeing, we're not seeing the same level of deferral among government insured patients that have, don't have to worry about co-pays and deductibles. We are seeing the deferral among patients that have co-pays and deductibles, and we can deduce that it's commercially insured. And we know that those co-pays and deductibles are increasing year-on-year, so it's becoming a bigger burden. In terms of the pace at which recovery comes, hard to estimate that. I wouldn't want to get ahead of myself on that one.

Jason Johnson

Yes, and maybe one other way to think about the population of patients who we think are deferring, I mean, the median income in our markets is like $68,000 a year I think something like that which is below the national median so I don't I think that probably, generally our market tends to be cost conscious.

Kevin Hammons

And they have same deductibles as everyone else has.

Jason Johnson

based on that, to the extent they can defer.

Andrew Mok

Got it. That's helpful. And if I could just follow up, I think your revised ACA headwind implies that the headwind gets a little bit better from 3Q into 4Q. Is that right? And can you explain the rationale behind that? Thanks.

Jason Johnson

Yes, thanks for asking that. We hadn't exactly clarified that. After the second quarter, we estimated that the impact of the HICS disenrollment and movement to self-pay would have about a $50 million to $75 million annual impact. That amount ended up being $30 million to $35 million in the third quarter, and we now expect the full year to be $80 million to $90 million. So, kind of at the midpoint, that's about a $20 million to $30 million increase from our previous estimate. We do think that the fourth quarter will go down to maybe $25 million to $30 million, so just slightly from what we saw in the third quarter. And that's because the prior year third quarter had the highest amount of HICS volumes and revenues for the year. We think that kind of comes down a little bit. We saw it come down a little bit in the fourth quarter, at $25 million.

Operator

And that concludes our question and answer session. I'd like to turn the conference back over to Mr. Hammonds for any closing remarks.

Kevin Hammons

Thank you everyone for joining the call today. As always, if you have additional questions, you can reach us at 615-625-7000. Have a good day, everyone.

Operator

Thank you, sir. And that concludes today's conference call. We thank you all for attending today's presentation. You may now disconnect your lines and have a wonderful day.

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