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Tenet Healthcare Corp (THC -3.35%)
Q3Â 2020 Earnings Call
Oct 21, 2020, 10:00 a.m. ET
Contents:
- Prepared Remarks
- Questions and Answers
- Call Participants
Prepared Remarks:
Operator
Hello, and welcome to Tenet Healthcare Corporation's Third Quarter 2020 Earnings Conference Call. I will now turn the call over to Regina Nethery, Vice President of Investor Relations for Tenet.
Regina Nethery -- Vice President of Investor Relations
Thank you. We're pleased to have you join us for a discussion of Tenet's third quarter 2020 results, including an update on the impact of the COVID-19 pandemic. Tenet's senior management participating in today's call will be Ron Rittenmeyer, Executive Chairman and Chief Executive Officer; Saum Sutaria, President and Chief Operating Officer; and Dan Cancelmi, Executive Vice President and Chief Financial Officer.
Our webcast this morning includes an accompanying slide presentation, which has been posted to the Investor Relations section of our website tenethealth.com. Listeners to this call are advised that certain statements made during our discussion today are forward-looking and represent Tenet management's expectations based on currently available information. Actual results and plans could differ materially. Tenet is under no obligation to update any forward-looking statements based on subsequent information. Investors should take note of the cautionary statement slide included in today's presentation, as well as the risk factors discussed in our most recent Form 10-K, subsequent Form 10-Q filings and other filings with the Securities and Exchange Commission.
With that, I'll turn the call over to Ron.
Ronald A. Rittenmeyer -- Executive Chairman & Chief Executive Officer
Thank you, Regina, and thank you everybody for joining us today. Our third quarter results, I believe underscore the operational discipline that we've put into action on an ongoing basis. As the pandemic has continued to evolve in waves, we have successfully met each sharp turn with a carefully coordinated and active response. Every step we have taken remains anchored by our commitment to the highest standards of quality and safety. We're very pleased with the performance of each of our business segments during the quarter. Despite the COVID-19 case surge, which was about 60% plus in late July and August compared to the second quarter, across our system, we delivered solid performance in every part of our business. While we experienced a surge, we safely handled caring for the COVID and non-COVID patients. Notably, our performance overall for the quarter was strong in delivering EBITDA at $621 million without grant income. Additionally, our free cash flow was 26% above 2019 before grants and Medicare advance dollars were considered, due in part to significant improvements from our Conifer operation. However, due to the new guidance issued by HHS in September, which was markedly different than the original guidance we had in June, we had to reverse $70 million from Q2 in grant dollars, thus lowering our reported Q3 EBITDA to $551 million. We strongly believe this guidance from HHS just does not recognize the structural differences across complex networks involving multiple hospitals, including mix differences in reimbursement levels in the different service areas, capital investment made in 2019 and early 2020 to effectively improve patient access and quality, as well as the incredible losses experienced in the shutdown that need to be recovered to ensure sustainable operations. We continue to discuss these details with HHS in hopes of a more balanced outcome. But regardless, we remain optimistic on our performance and our ability to continue to improve.
What should be more evident is that the operational enhancements we've highlighted on the past earnings calls have played a major role in continuing to provide benefits across the enterprise. Our continued performance should substantiate, these are not one-time events but sustainable and critical foundational improvements. For example, enhance the analytical tools and pull through a precise real-time data, which we continue to refine and develop with deeper insights; knowledge sharing from COVID learnings real time across the company summarized and transmitted in technical and operational schedule calls that have resulted in improved response to patient needs and an average staff infection rate of approximately 3.75% versus a national average of approximately 13.4%. That focus ensures we remain open to both COVID and non-COVID cases safely and effectively, even while dealing with isolated market surges such as in the third quarter.
We've also demonstrated solid sustainable controls, which include responsive workforce adjustments and tightly controlled labor market -- management, continued development of our IT platform focused on delivering a streamlined set of tools, utilization of cloud-based infrastructure and a much improved cyber platform, better purchasing and contracting methodologies, tighter capital controls and allocations based on defined needs by market. We've also added highly qualified physician groups based on community need, tighter controls in the Tenet Physician Resource group and consistent improvements to ensure physicians have an efficient and effective methodology to assist in their ability to support patients. And finally, the continued expansion of our very capable and effective Global Business Center in Manila has been an important enhancement to our 24/7 support model.
In hospitals, volumes for the quarter ended close to 90% of pre-COVID levels. This is continuing to be a solid recovery during the time period and remains very positive. Our operators across our markets have responded very well, given the nature of the complexities of the pandemic, and we continue to perform tightly aligned to the volumes presented. We've experienced historically high growth in net patient revenue per adjusted admission, driven in part by a higher mix of more complex procedures and a stronger commercial mix, coupled with the sustained efficiencies we've gained operationally. Importantly, this set of improvements is represented both in the hospitals and the USPI, further emphasizing the critical nature of how hospitals in USPI play an integral role with each other, including sharing best practices.
We realize and operate every day with the assumption that the COVID spikes will be part of what we face until a vaccine becomes widely deployed. We've learned how to deal with these spikes and have done so effectively. We also are aware the pandemic remains a threat, and our focus on staff and facility safety will continue to be paramount in our daily approach. We continue to use resources internally and externally, including contract labor to support our operations as needed. We remain engaged in securing sufficient PPE, supplies and medications to ensure we have adequate coverage.
Most importantly, we also realize that agility, speed to respond and the need for clear, precise communications coupled with a strong and responsive real-time analytical platform throughout our system is a critical part of remaining in control of these changes and surges. There is no perfect equation, but we do believe our learnings from each spike improves our responsiveness, our planning and furthers our effectiveness.
At USPI, the quarter was very strong, demonstrated first and foremost by solid performance, but also carried by excellent quality and service recognition, service line expansion and the growth of our medical staff. Excluding grant income, USPI had a significant EBITDA growth of 10% over prior year. As you can see on the volume charts, surgical cases remained relatively steady in terms of volume month to month, ending with September growth at 96% of the same period last year. Even with the impact of the various shutdowns and cessation of nearly all elective care that began in the first quarter, the USPI team has remained diligent about energizing various operational programs to enhance facility offerings and expand our network. This includes adding service lines and complex procedures that benefit patients and physicians alike. Despite the pandemic and its disruption, we have successfully expanded our offerings at existing facilities with 54 new service line starts year-to-date, including 24 muscular-skeletal programs and outpatient joint growth of 51% year-over-year. Another remarkable stat that underscores our reputation in the market is that we've added 1,100 new surgeons who have joined our USPI medical team during the first nine months of the year.
USPI facilities also continue to earn high marks for patient experience, including Press Ganey awards last month for delivering incredible patient-centric care. Additionally, 23 of 24 eligible USPI surgical hospitals are in the 4- or 5-star rating in the July 2020 HCAHPS Star Rating, as administered by CMS.
Particularly during COVID, we have adhered to the highest quality and safety standards. Out of more than 688,000 USPI surgical cases performed from mid-March through September, we have not had a single confirmed case of COVID as a result of performing a surgical procedure at our facilities.
At the development front, we closed on the acquisition of an ASC in Washington and the new surgical hospital and ASC in the Central Valley of California in July, together with local physicians and two of our existing health system partners. Fresno Surgical Hospital is very well known in the community, with a rich history and a strong reputation for quality and patient experience. In fact, years ago, the hospital became one of the first facilities in the country to provide elective surgery and post-surgical care in a non-hospital setting.
Going forward, our pipeline remains active with opportunities to strategically add to our network in Q4 and next year. We're very enthusiastic about continuing our stated strategy to put muscle behind USPI to grow the platform and provide physicians and patients with more convenient options for care and to continue to evaluate our hospital portfolio for CIT [Phonetic] and make adjustments in that portfolio as we deem appropriate.
Conifer continues to execute very well despite the pandemic, providing value to its clients with its traditional end-to-end solution and its newer point-of-service solutions. Conifer has remained focused on client satisfaction, performance and liquidity. I want to call out a few metrics that speak to certain improvements. First, cash collections were up substantially as compared to the third quarter of last year. Second, Conifer AR days or Tenet AR days are significantly down versus the prior period. Third, client satisfaction continues to improve, maintaining a very strong positive trend. And fourth, expense controls remain solid with an EBITDA margin improvement of 270 basis points versus the prior year. These steps forward are particularly notable, given the extreme challenges created by the pandemic for Conifer.
The Conifer spin remains ongoing, in terms of the pre-work already discussed. Our views are same as last quarter, regarding the spin. And we continue to maintain focus on the previous schedule. We have filed the appropriate paperwork on schedule with the IRS. So, that important step is now under way. Beyond that, we continue to search for new Conifer CEO and have made several meetings with several viable candidates in this process. The team, overall, though, is performing very well and we are pleased with the overall performance of the business.
Before turning the call to Dan to provide an overview of our financials, I'll speak briefly to the critical support we've received from the federal government related to the pandemic.
The Medicare advance payments have been a critical source of liquidity, allowing us to focus on caregiving. Recently, the repayment terms for these advances were amended, allowing for an elongated capture period by CMS, as well as a more reasonable interest rate for any balance outstanding at the end of the recapture period. We expect to make the repayments within the allocated recapture timeframe and greatly appreciate this flexibility provided by CMS and HHS.
The CARES grant stimulus funds have also been extraordinarily helpful. As I mentioned, HHS just recently issued new guidance for the recognition of revenue associated with the stimulus funding, which has had a major impact on our results this quarter due to the reversal from the second quarter. While the change in methodology will reduce our flexibility, we're taking steps to ensure the change does not negatively impact us over time. Our system, as I've mentioned, has incurred a larger number of COVID cases in general. And we feel that we've taken it in stride and the change in methodology will place additional pressure on us in the recovery over time relative to the COVID cases, but we also believe we will continue to recover these CARE grant stimulus funds. It will just be over a longer period of time than we thought we were originally getting based on the June guidance. So again, we're not concerned that are hurdles over time; we just think it is unfortunate that we had to make the change.
So as I turn the call over to Dan, I want to note how pleased we are that we're able to take advantage of the capital markets position us even more favorably in terms of both debt maturities and interest rates. While we do have many more hurdles yet to overcome, the performance of the teams across the entire Tenet portfolio remains excellent. Our performance in safety, quality and financially, despite the pandemic, is very positive. And while we can sit here and parse various points and speculate on the unknown, factually, we have consistently delivered results at or ahead of expectations before and during the pandemic. I'm very proud of our caregivers and our support staff for their continued excellence.
So with those comments, I'll turn it over to Dan for a discussion of the financials. Dan?
Daniel Cancelmi -- Executive Vice President & Chief Financial Officer
Thanks, Ron, and good morning, everyone. I also want to thank our front-line caregivers and employees across the company for their incredible efforts and exceptional execution during these very difficult times. I'll begin my remarks with Slide 5. As you can see there, we produced a very strong quarter from several perspectives. Our adjusted EBITDA of $621 million before the $70 million grant income reversal due to the new government guidance was substantially above our expectations for the quarter, despite the surge in COVID in many of our markets. And also, the EBITDA was above consensus estimates if we exclude the grant numbers that were in the consensus numbers. We generated very strong net revenue per case growth in our Hospital and Ambulatory businesses, and there's a total mix of higher acuity cases and a more favorable commercial payer mix. Our continued tight control of costs mitigated the impact of incremental expenses from the pandemic, including higher temporary labor, premium pay and PPE costs.
We also generated solid free cash flow in the quarter of $331 million or 26% growth, even if you exclude stimulus monies we received. And we are pleased to be able to timely access to capital markets and eliminate any significant debt maturities until June 2023, while also reducing future annual cash interest payments by about $50 million. While we typically do not comment on consensus, we realized that the level of stimulus grant income and the consensus is not always readily apparent to everyone. One estimates the third quarter consensus estimates roughly at an average EBITDA benefit from grant income of about $70 million. This compares to the $70 million negative reversal of grants that we had to record this quarter due to the new guidance.
Our other individual business units, each segment continued to execute well, demonstrating the ability to operationalize the strategic direction of the company, despite the day-to-day difficulties of the pandemic. Our Hospital segment produced historically high net revenue per adjusted admission growth of about 17%, driven by a combination of higher patient acuity, more favorable commercial trends, as well as negotiated rate increases. This growth confirms the incremental labor and supply costs associated with the significant increase in COVID cases over the summer. Hospital admissions starting the third quarter were approximately 60% higher than what we experienced in the second quarter.
As well as the Ambulatory business generated strong top-line growth with revenues for surgical case of 13% on the same facility systemwide basis, which drove surgical net revenue growth of 6.3% compared to last year. This growth was also attributable to higher patient acuity, as well as growth through procedures from newer service lines. In terms of adjusted EBITDA, USPI delivered a year-over-year growth rate of 10%, excluding a $13 million grant income reversal. Despite surgical volumes being about 6% lower than last year, USPI's adjusted EBITDA margin for the quarter excluding the grant reversal was 40.4% compared to 39.7% last year.
Conifer also continues to exceed our expectations, especially its cash collection performance for our hospitals and its other clients. And Conifer's adjusted EBITDA was 7% higher than last year and as Ron pointed out, its margins increased by 270 basis points, primarily due to various cost efficiency initiatives that we have been executing on over the past several quarters.
Let's turn to Slide 6 now and review how our volumes trended during the quarter. The steep surge in COVID cases, hospital admissions, ER volumes and surgeries held relatively steady compared with the month of June, while outpatient visits grew as patients became more comfortable with the safety of seeking elective care. Quietly [Phonetic], more complex and emergent procedures have recovered from the pandemic at a stronger pace than less critical lower acuity care. ER volumes are an example of more critical care recovering at a faster rate, and ER inpatient volumes during the quarter was about 93% of last year's levels, while outpatient ER volumes were about 74% of last year's levels.
As I mentioned earlier, the higher acuity more emergent mix drove a very strong hospital net revenue per adjusted admission growth of 17% in the quarter. USPI surgical volume trends improved during the quarter compared to the month of June, recovering to about 96% of last year's levels in September and 94% for the entire quarter. Similar to our hospitals, USPI's more critical higher acuity cases have rebounded at a stronger rate than lower acuity cases. This mix also drove USPI's very strong net revenue per case growth as well. Although not on the slide, if you look at the supplemental materials we posted, you also see on Page 6 that USPI's non-surgical visits grew about 8% in the quarter and that was driven by very strong growth at our urgent care centers.
Let's now move to Slide 7, which reflects how our EBITDA trended each month during the quarter with and without the stimulus grant funds. As we mentioned last quarter, we are providing this monthly information externally in the interest of full transparency, given the unprecedented nature of the pandemic. As a reminder, the top section of the slide shows our monthly EBITDA in the quarter without the grants. The middle section of the slide highlights the grant income we recognized in July and August, before the rules were changed. And then we also point out the amount we had to reverse in September due to the new guidance and the bottom section of the slide summarizes our EBITDA, including the grant activity. You'll see in the top section of the slide, even as COVID cases began to ramp back up again in July, our EBITDA in July, excluding the grants, was $220 million, which was consistent with the month of June. As COVID cases continued to accelerate, our August results did moderate, but our EBITDA in September grew sequentially as we continued to adapt operationally and COVID levels declined. An important point is that before the grant reversal, our $220 million EBITDA performance in the month of September was above our original pre-COVID budget for the month, even though our volume were about 5% to 25% lower than last year, depending on which volume metric you look at.
Overall, we are pleased with how our operators managed through these times and produced EBITDA for the quarter before the grant reversal that was substantially above our expectations, despite the elevated COVID levels.
Next, let's go to Slide 8 and review our liquidity. We currently have sufficient cash resources and available liquidity under our $1.9 billion line of credit facilities. As of Monday, we had approximately $3.3 billion of cash on hand and no borrowings outstanding under the line.
Let me now provide an update on Medicare advances. As you may recall, we applied for and received approximately $1.5 billion of accelerated payments, substantially all of which was received in the second quarter. Originally, repayment of the advances was scheduled to begin in August. However, in the continuing resolution signed by the President on October 1st, the repayment timeline for the advances was extended. The repayment period now begins next April, April '21, rather than this past August and extends through September of 2022. Also, any balances not repaid by September '22 will be subject to a 4% interest rate rather than a 10.25% rate under the original repayment terms. We certainly appreciate this government's support and the repayment period being extended as it alleviates a substantial near-term cash outflow providers were facing, while confronting the challenges of the pandemic. Also, just an update on the amount of grant funds we received. We received additional stimulus grant funds of $178 million in the quarter and to date, we've received about $890 million of grant funds. Of this amount, $453 million has been earned so far and recognized as grant income. Given the new guidance and the uncertainty as to the level of future COVID cases and cost, it is difficult to predict with any precision how much of the remaining grants of about $437 million will be earned by us in future months.
Before I wrap up my remarks, let's now turn to Slide 9 to discuss our noteworthy cash inflows and outflows during the quarter. You may recall, last quarter, that we discussed our objective was despite the pandemic was to not burn through a material amount of cash in the second quarter, excluding stimulus funding and proceeds from issuance of new notes. We did accomplish that last quarter and we did so as well again this quarter. In fact, in Q3, we produced strong net cash flow growth excluding those items I mentioned of about $231 million. One other item I wanted to point out was that we did accelerate $105 million of interest payments into the third quarter that normally would have been paid in October and that was due to us early retiring our notes that were scheduled to mature in 2022. We also continue to be very diligent and thoughtful about how we allocate capital, including capex. You will recall, at the outset of the pandemic, we -- to ensure we preserve sufficient liquidity, we dialed back our anticipated capex spend for 2020 by about 40% to $425 million from our original estimate, which was $725 million. Given the various actions we've taken over the past two quarters to enhance liquidity and our improved cash collection trends, driven in large part by Conifer's strong performance, we now estimate that our 2020 capex spend will be about $525 million. These additional investments are primarily attributable to growth capital opportunities and necessary spend for COVID.
With that, I'll end by saying again that we are incredibly grateful for the unwavering efforts of our patient caregivers and the employees during the pandemic.
I'll now turn the call back over to Ron.
Ronald A. Rittenmeyer -- Executive Chairman & Chief Executive Officer
Thanks, Dan. I don't really -- No other comments to add. I think we've covered everything, And I think it'll be smart, if we get into questions. So, we've got about half an hour, I guess, dedicated left to couple of questions. So, operator?
Questions and Answers:
Operator
Thank you. The Tenet management team is now ready to take your questions. [Operator Instructions]. Our first question today is coming from A.J. Rice from Credit Suisse. Your line is now live.
A.J. Rice -- Credit Suisse -- Analyst
Hi, everybody. I [Indecipherable] You guys have obviously been trying to do assessments in the market, data analytics around these different hotspots and you sort of had a unique portfolio where you had some markets that were hit early on pretty hard. And then you're in other markets that have had the hotspots develop. Can you maybe just drill down a little bit on how you feel you are at being able to predict where the next hotspots are going to be, what you've learned in terms of managing through a hotspot and also assessing how the community is managing through that hotspots and then coming out the other end and recapturing deferred procedures and things like that?
Ronald A. Rittenmeyer -- Executive Chairman & Chief Executive Officer
Okay. The long-term there. Saum, do you want to handle that?
Saum Sutaria -- President & Chief Operating Officer
Yeah, sure. Thanks, thanks for the question. I think we've -- in terms of predicting where the hotspots are going to be. I mean, we obviously follow very carefully a lot of the public health information that's available with respect to new testing, positive testing incidence rates and the -- you can really track the spread of the virus that way pretty quickly. Obviously, by the time these cases are hitting our urgent care centers or emergency departments, it becomes quite obvious there is going to be a surge. I mean, what we've learned is generally speaking, there is somewhere between four- to six-week cycle that you'll go through in a market when there is a COVID surge. Usually, there is a couple of weeks of ramping up. You end up spending about four weeks kind of at a high-level plateau and that mix includes both med-surg and ICU patients. And then, it sort of ramps its way down. Our priority during that phase, obviously, is maintaining very good throughput and operations within our environment, separating COVID from non-COVID care. Our focus on having adequate PPE and testing has allowed us to make sure that we are able to process those patients adequately but also keep our staff safe. We've not had, especially in recent surges, any need to shut down procedures or elective surgeries. That's a very important point, because we want to maintain access for the community. And then as those cases ramp back down, we ramp back up very, very quickly. That's probably the most important thing that I focus on, which is at the end of that six-week period, that recovery work is a playbook that we've got down from having had a number of markets go through surges. And our September result is very much a reflection of that. If you look at the COVID activity in the quarter, it was very much spiking in the first part of the quarter. By the end of the quarter, as those cases had ramped back down, we're very capable of getting back to normal business, getting anything that was deferred on the schedule, and most importantly, working with our community and doctors to ensure that the patients in the community realize that they can come back into the hospital for necessary care. And that really is why when you look at September, the results reflect basically our ability to get back to business as usual from patient care and from an earnings standpoint.
A.J. Rice -- Credit Suisse -- Analyst
Okay, great, thanks.
Operator
Thank you. Our next question today is coming from Josh Raskin from Nephron Research. Your line is now live.
Joshua Raskin -- Nephron Research LLC -- Analyst
Hi, thanks.
Ronald A. Rittenmeyer -- Executive Chairman & Chief Executive Officer
Hey, Josh.
Joshua Raskin -- Nephron Research LLC -- Analyst
Good morning, appreciate you guys taking the questions. Hi, Ron. I wanted to ask about the increase in revenue per adjusted admission and just try to break out the buckets there, and how much of that is coming from actual patients? It sounds like that was a bigger impact than I had expected. How much of it is mix, specifically commercial, and how much of it is actual acuity? And then within that, how are you and your physician partners prioritizing the patients and the procedures that come back first? It sounds like you're getting more of the high acuity and more of the commercial back and I assume that's similar in ASC.
Daniel Cancelmi -- Executive Vice President & Chief Financial Officer
Hey, Josh. It's Dan. I'll start off and then have Saum address the last point. But, it was in the 17% growth in the revenue per case on the Hospital side. All three of those components have some element to it. The predominant factor driving the growth in the net revenue per adjusted net is due to the higher acuity cases. And wasn't -- The COVID is part of that, right? But that's not the primary driver of it. You have the mix of higher acuity cases. You have a stronger commercial mix compared to our overall volume trends, which makes sense to a large degree Medicare patients who are probably a little more reluctant to seek care unless it's necessary. So, the commercial trends are more favorable than the overall trends. There is also the growth in the revenue yield due to our contracting position. We've been very clear about that over time. We're very well contracted this year and into next year, and our growth just from negotiated rates is depending on the facility, can be -- and depending on the payer; can be 3%, 4%, 5% or so. So, they've all played a part. I would say, in terms of -- Let me just address this COVID and the revenue yield from that. I would say this, before I turn it over to Saum. Yes, in aggregate, the net revenue for COVID cases is higher than the overall net revenue per admit. Okay? But you've got to keep in mind, you have the case mix adjust that rate. There is obviously incremental cost caring for those type of patients. And when you case mix adjust for that rate, it's very similar to what the overall net per admission is. And the other thing I'd point out, in terms of the mix of the COVID patients, COVID patients related to commercial payers is roughly 20% of the total COVID cases. So, the other 80% is either Medicare or Medicaid or uninsured. As you well know, obviously, the commercial reimbursement would be a more favorable than the other payers. But again, it's very important to consider the fact that when you case mix adjust those particular type of services and when you consider the cost, the incremental costs associated with them, the profitability isn't necessarily there that a lot of people think is there. I don't know if there's anything else you want to add, Saum?
Saum Sutaria -- President & Chief Operating Officer
Yeah, I mean, I'd make a couple of points to you, again, just thinking about what I said, which is the most important thing to really look at is the nature of the recovery. So, let me frame it this way. When you think about the number of COVID cases from the beginning of the quarter, declining at the end of the quarter and we're basically able to maintain and rebuild the business at roughly 10% under prior year, the thing I would tell you is that the commercial -- as Dan pointed out, the commercial admissions performed better than that. And more importantly, given our long-term strategy of building a base of higher acuity procedures and services, our commercial surgeries, and you can see the surgery numbers look more attractive. Even the commercial surgeries were performing, by the end of the quarter, better than those averages. So, even surgeries are not really relevant in the COVID environment. So, what we did was we built back, consistent with our long-term strategy, the strength in the surgical environment that we have been pursuing for the last couple of years, including having a number of markets that we're performing better than prior year, especially in commercial surgeries. And if you say what's driving that? Well, I mean even over the last four or five months and primarily in the last quarter, we've opened up and built two new trauma programs. We have a new and expanded neurosurgical and spine program in South Florida across multiple hospitals, that's been coordinated big push in surgical oncology and building a network in San Antonio. I mean, there are just a number of things in rebuilding the strength in our business, very specifically consistent with our long-term strategy that we have continued to execute on over this period of time. And that's helping to drive the strength in the recovery. So, as I pointed out before, the COVID cases may come and go. Even on a commercial basis because the cost of those cases are high, I would never want to substitute a COVID commercial case for the types of business that we're building. We, obviously, do the best we can to take care of those patients. But we're very quick to recover in the normal lines of business that we've been strategically focused on.
Joshua Raskin -- Nephron Research LLC -- Analyst
Perfect, thanks.
Operator
Thank you. Our next question today is coming from Justin Lake from Wolfe Research. Your line is now live.
Eugene Kim -- Wolfe Research -- Analyst
Hi, good morning. This is Eugene on for Justin. Thank you for the question. As a follow-up to Josh's question earlier, are you able to quantify the number of COVID-related admissions during the quarter? And I think you said COVID mainly impacted July and August. So, can you comment on how your admission volume and acuity were tracking toward the end of September and possibly early October? Thank you.
Daniel Cancelmi -- Executive Vice President & Chief Financial Officer
Yeah, this is Dan. Let me address a couple of those points. The COVID inpatient centers in the third quarter was about 15,000 cases. And as we pointed out in our remarks, it's roughly 60% higher than the second quarter. One thing that's important to keep in mind with the previous conversation we just had, the sequential change in earnings from August to September was not due to the mere growth in overall cases. Our -- In fact, our admissions were actually about 1% or lower in September compared to August. So, you see the impact the COVID cases have on earnings. In August, when the COVID cases were higher than September, it did, it had an impact on earnings. That sequential growth in EBITDA from August to September was not just due to, well, cases were higher, normally because that's sequentially what happens. Our aggregate volumes in September were roughly down 1% compared to August. But you see the growth in the earnings from August to September as the COVID cases declined.
Operator
Thank you. Our next question today is coming from Pito Chickering from Deutsche Bank. Your line is now live.
Pito Chickering -- Deutsche Bank -- Analyst
Good morning, guys. Thanks for taking my questions. I'll sort of ask the same question in a different way. There's obviously a pretty big debate on the investment community about the sustainability of hospital EBITDA observed during the third quarter. So, a multipart question. Any chance you can give us how much sort of EBITDA in third quarter came from COVID and more specifically, how much you saw in September? I understand this doesn't give a whole picture, but at least, help us understand how that works. And more importantly, can you give us color on your October trends? What you've seen? What are you seeing in November or scheduling block times? And then walk us through the headwinds and tailwinds, help us think about the revenues and margins over the next few months.
Ronald A. Rittenmeyer -- Executive Chairman & Chief Executive Officer
Well, that's three questions. We'll do our best. So, Dan, do you want to start?
Daniel Cancelmi -- Executive Vice President & Chief Financial Officer
Hey, Pito. It's Dan. Yeah, let me try to address and Ron or Saum can fill in. In terms of -- We obviously haven't provided EBITDA by service line. But again, I'll go back to when COVID levels were much higher in August, it had an impact on our earnings. In August, you could see the sequential change from August to September. Our -- Again, our aggregate volumes from August to September were roughly flat or down about 1%. Let's just call it flat. But earnings increased and in large part, that was due to COVID cases leveling off and coming down. The COVID cases have substantially more costs associated with them, particularly if they get -- if a patient ends up in the ICU. And I said earlier, yes, the revenue per COVID case that we've experienced per admit so far is higher than our aggregate net revenue per admit. But again, the [Indecipherable] acuity, Pito, as you know, of those cases is higher and that brings with it incremental cost. That's why I said when you case mix adjust it, it's pretty close to what our average net per admission is. So, that I think -- Saum, I don't know if there is anything else you want to add?
Saum Sutaria -- President & Chief Operating Officer
Yeah, I mean, I think a couple of things. So, I think it's important to realize that the nature and mix of our COVID activity given the markets we're in and the types of -- especially types of urban centers that we have, as Dan pointed out earlier, are not -- they are not mix enriched. In fact, relative to our average, it's slightly below our commercial mix. So, we're dealing with a lot of work in the Medicare, Medicaid and even uninsured space with respect to the COVID care that at least we're seeing in our system. Again, a consequence of some of the markets that we're in. And so when you look at September, again, I don't have any other way to do this, but just continue to give additional examples of what we're doing to drive the recovery. So in addition to some of the stuff I mentioned before, I mean, we've had expansions in many of our surgical service lines, very consistent with our strategy over the last couple of years. We've built the robotics and [Indecipherable] program in El Paso. We've got rehab facilities that we've expanded in South Carolina. We've got a CT surgery program that has gone through material expansion in parts of Texas. I mean, our point has been continuing to advance the strategy of expanding surgical service lines for the community as a way to drive and be prepared to manage the recovery over time, recognizing that some of the lower acuity business that was in hospitals, let's say, very low acuity ER visits, may take a long time to come back. And so, we're not trying to create a replica of what 2019 looked like from a mix. We're looking at where the market is headed. And we're trying to address that market as part of our recovery. And not surprisingly, the comments that Ron made earlier about USPI were tracking exactly the same way. The expansion of our physician staff there has been in primarily higher acuity specialties. The number of orthopedics programs and even the number of orthopedics cases, for example, in that environment has grown materially, because we're basically servicing where the demand is rather than trying to create a replica of 2019. I think that's going to end up serving us well over time rather than trying to wish for everything that was in the hospitals, including the low-acuity business to come back. And it ought to drive an enhanced earnings profile because of the case mix intensity in net revenue per case that becomes more sustainable.
Pito Chickering -- Deutsche Bank -- Analyst
Then, can you give color on the October and November trends or scheduling? Thanks.
Saum Sutaria -- President & Chief Operating Officer
I mean, our -- We don't show any signs of a shift from the strength that we saw in our September recovery, as I look forward. And I can look at that at any metric, whether it be our scheduling of cases at USPI or the hospitals from a surgical standpoint or high acuity service standpoint that we're looking at at this point at all -- at this point in time at all.
Operator
Thank you. Our next question today is coming from Whit Mayo from UBS. Your line is now live.
Whit Mayo -- UBS -- Analyst
Hey, thanks. Good morning. I wanted to shift topics a little bit and go back to USPI. Maybe for Saum or Brett, the 1,100 new doc adds. I was wondering if you could frame that relative to your current base. And I think I heard Saum say that in terms of specialties, I think, ortho was certainly an additional benefit there. And resyndicating more equity to these doctors or are these doctors that are just moving their business? I guess I'm trying to sort of frame how sustainable you think the volume is, from the new one-thousand doc adds.
Ronald A. Rittenmeyer -- Executive Chairman & Chief Executive Officer
Yeah. Brett, please comment.
Brett Brodnax -- President & Chief Executive Officer, USPI
Yeah. Hey. How's it going, Whit? So, just to back up a little bit. We've certainly seen an increase in the number of physicians that are interested in operating in the ASC setting. That's without question. And as Ron mentioned, we've added over 1,100 physicians to our medical staffs just this year. And that's partly as a result of COVID, but I think the increase is more related to our ongoing business development and service line expansion activities. And there is no question, some physicians are moving more of their business to ASCs as a result of patient preference, related to COVID. But others are simply continuing to find it's a more efficient site of care for their surgical patients. If you -- Going back to your question related to how much of an improvement that is over our base, you think we have about 10,000 -- we have about 4,000 physician partners across the portfolio, about 10,000 physicians on our medical staff. So, this represents, in the nine-month period, over a 10% improvement in the number of physicians on our medical staffs overall. I don't have a specific breakdown in terms of how many of those are partners versus non-partners. As you know, some -- most physicians joined our medical staffs. They make sure it's a good fit for them, good fit for their patients, good fit for the overall partnership. And then at some point down the road, they may exercise the opportunity to actually buy into a partnership, but that's not our focus day one. Our focus is making sure that we bring in the right high-quality physicians to our medical staffs, that they're happy with the service that we're delivering to them and their patients and then over time, we add those physicians potentially as partners to our facilities. So, I think the number and the amount of physicians that we've added to our medical staffs over the first nine months is clearly better than we have in historical years and again, primarily, I think a result of our business development activities and our service line expansion activities and to a minimal degree, a result of the COVID-related activity.
Whit Mayo -- UBS -- Analyst
Perfect. Thanks a lot.
Operator
Thank you. Our next question today is coming from Brian Tanquilut from Jefferies. Your line is now live.
Brian Tanquilut -- Jefferies -- Analyst
Hey, good morning. I guess I'll follow up on that comment from Brett and Saum's comment earlier to Pito's question. So, I think that there is a structural change that's happening. That's actually not a bad thing. We are -- You're pushing your procedures or visits either to the ASC, whether is joint replacements or ER visits that are low acuity going to urgent care. And how do you think that -- If that's the case, what should be the margin looking forward?
Saum Sutaria -- President & Chief Operating Officer
Yeah, that's a good question. And let me clarify what I said before, which is what we're focused on is understanding where the demand is today and making sure that we're leading the charge in helping to service that demand by shifting our focus into the areas where we see that activity happening. In other words, the higher acuity surgical, higher acuity emergency department, even our -- we track very carefully even our emergency department visits by acuity level and at the higher acuity levels, we're performing better than we were in prior year. So, those data have some lag to them. But when we look at our own data, we are convinced that in our high-acuity ER business, we may be moving market share. And so, again, we're very focused on that. The clarification I would offer is, look, I'm not yet committed to saying that there is a major shift in the demand pattern that's permanent as a result of COVID, especially in the lower acuity areas. When I look at the areas, lower acuity areas in particular that are down quite a bit, for example, they're much more down in pediatric visits than in other services, especially in the emergency department. Okay? Schools are not back online. Sporting programs that kids are in are not back online. I don't know that that's some sort of a shift from the ER to the urgent care setting. I just think demand is down because activity is down because of partial stay-at-home orders that are still active in many of the markets we're in. And I would say that's true for a variety of other activities that result in ER visits. And you're not going to get a broken bone fixed and set necessarily at urgent care centers permanently in the future or in other centers. So, I actually think some of that demand will come back as the communities fully open back up, schools fully open back up and other things, but it may take some time. And so my point was, attempting to work that side of the equation right now doesn't make a lot of sense. But again, I'm not yet committed to the concept that that demand has gone forever from hospitals. We'll see how that plays out over the next year or two. And it's clear that telemedicine won't be able to service a lot of those types of injuries and stuff that drive a lot of low-acuity visits. It will go somewhere. It's just a question of how much will come back to hospitals. Does that help?
Brian Tanquilut -- Jefferies -- Analyst
Yeah, no, that's exactly what I was looking for. Thank you, appreciate that.
Operator
Thank you. Our next question today is coming from Kevin Fischbeck from Bank of America. Your line is now live.
Kevin Fischbeck -- Bank of America Merrill Lynch -- Analyst
Great, thanks. I wanted to get a sense of how you're thinking about the incremental profitability of volumes are turning back to normal. I guess, obviously, usually, we think about incremental volumes coming out with a nice fixed cost leverage. But if we're talking about lower acuity volumes coming in, how should we think about that? And then, I guess, incrementally, you've been able to manage labor. Does that get more difficult as volumes come back? I just want to think about the interplay of low acuity and potentially labor cost pressure as volumes come back, and how we should think about incremental margin on future normalized growth. Thanks.
Saum Sutaria -- President & Chief Operating Officer
Yeah. Good question.
Ronald A. Rittenmeyer -- Executive Chairman & Chief Executive Officer
Saum, do you want to...
Saum Sutaria -- President & Chief Operating Officer
Yeah, I can start and Dan, you can maybe add on it. Good question, because as you move to a higher acuity mix, obviously, you're going to need more support and staff, especially in the ICU and critical care units and other things. Thus far, we have not seen a tremendous amount of pressure related to the work that we're doing more strategically in expanding in those areas. I would point out again that as COVID surge has come through, we have had to use a fairly significant amount of contract labor in the quarter, especially in the first couple of months in the quarter, that affected our costs. But we've been very, very disciplined about using -- the question that was asked earlier, I think by A.J., about the predictability of these COVID surges and declines. We've basically gotten pretty good at just estimating how much contract labor we're going to need for how many weeks and then shutting it off, sometimes in advance of the surge disappearing because we know what the curve is going to look like. And that really is reflected in our September results from the standpoint of managing margins.
So, look, the other thing I would say is there is no question about the fact that the foundation we have laid over the last couple of years to have a more daily driven management process in our not just labor productivity but labor mix that we are utilizing for patient care has served us well and probably, has accelerated some of our recovery. And we have no intention of changing from that approach to management, even if the COVID activity dissipates or goes away more permanently with the vaccine. We know it's our responsibility to continue to drive efficiency in that setting. Probably, the more important opportunity, looking forward, for us, is also in the area of purchased services in many cases, which are labor-based. Right? So, many of the services that we have, either partnered with outsourcers or others, where we're really working on managing the productivity of that staff at the same time and that will result in incremental opportunities for savings as we right-size effectively to the portfolio of cases that we're seeing in the hospitals these days.
Brett Brodnax -- President & Chief Executive Officer, USPI
I'd just add to that that it also spills all the way through the -- That whole concept that Saum's talked about also spills through that we talked a lot about all the way back through our overhead and our overhead operations. Our global business center will continue to play a major role in better allocation of overhead and better allocation of support since that's a 24/7 type operation and it's staffed accordingly and it can be very responsive and it's done a great job through the pandemic. We've actually more than doubled the size of it through the pandemic, even while it was going on. So, that has proven to us to be a great source of balancing workload and balancing in the right places with really good talent, but at the same time, being able to be much more responsive to our facilities on a 24/7 basis.
Ronald A. Rittenmeyer -- Executive Chairman & Chief Executive Officer
Dan, do you have anything else you want to add?
Daniel Cancelmi -- Executive Vice President & Chief Financial Officer
The other thing I'd add is, Kevin, is you will recall before the pandemic occurred that we had been focused on over the past several years, realizing about $450 million of cost efficiencies since we started this back in 2018. And we're fully on track for that for this year and do what we -- And as we talked about last quarter, too, as a result of the pandemic, we've dug deeper. We've identified more efficiencies that we've been realizing or real realizing into the future. I mean, it's really across all of the cost elements of our cost structure, whether it's labor management, supplies or other operating expenses. Saum's point about some providers that were in other operating expenses. We've been renegotiating contracts, improving SLAs or service level requirements. And it had an impact and we also, with times, will take actions to terminate a contract even if it costs a little bit of money to get out of it, if long term the return is going to be better. So, obviously, we'll keep working on this and we feel very good about our ability to continue to manage costs well.
Ronald A. Rittenmeyer -- Executive Chairman & Chief Executive Officer
Yeah. The last point I'd add to, Kevin, is that we've added a significant amount of analytics and we look now in a much more database-driven finite level at where we have people, what are they doing, what's the impact of that, is there a better way to do it, where do we automate, where don't we automate. So, we approach all of this, I think, with a much clearer vision and the pandemic, to Dan's point, has enhanced and pushed us to question just about everything. So, I think we've become much more effective at this and over the next year, we'll even continue going deeper. So, I hope that answers your question.
Kevin Fischbeck -- Bank of America Merrill Lynch -- Analyst
Perfect. Thanks.
Operator
Thank you. Our next question is coming from Ralph Giacobbe from Citi. Your line is now live.
Ralph Giacobbe -- Citigroup -- Analyst
Great, thanks. Good morning. Just wanted to ask about the EBITDA trajectory. You've been running at a monthly level about $220 million for, I think, three out of the last four months. And then the dip in August, I think, you mentioned was related to some of the COVID activity and maybe the seasonality. I guess the question is, typically, we see a seasonal ramp into the fourth quarter. Do you still expect that to be the case and higher EBITDA run rate, or is that maybe unlikely to move from that $220 just given the underlying circumstance? Thanks.
Ronald A. Rittenmeyer -- Executive Chairman & Chief Executive Officer
It's a good question. Dan, do you want to jump first?
Daniel Cancelmi -- Executive Vice President & Chief Financial Officer
Yeah. Certainly, three of the last four quarters have been in that $220 million territory. As you mentioned, as we've talked about, August numbers were more moderate because of COVID. It certainly -- We obviously haven't provided guidance, but we're certainly working toward that [Indecipherable] some. The fourth quarter, as you know, is typically sequentially stronger, particularly on the Ambulatory side as well as the Hospital side, as patients have met their deductible in a given particular calendar year. Now, sometimes, we have seen a little bit over the past couple of years that people have maybe managed the bag a little bit differently than in the past. But last year, the fourth quarter was incredibly strong. We'll have to see. We don't know. Right? We'll have to see how it plays out this year. We are obviously working toward driving incremental volumes in the fourth quarter, and you've seen the trajectory with the Ambulatory business had some improved nicely. And again, just putting COVID aside for a second, because we've -- if there are significant spikes, obviously, we'll have some type of impact. But we're going to be working for sequential growth and I think the big variable is ultimately going to be two things. One, the level of COVID; and two, the comfort in level of patients returning to facilities, whether they are hospitals or surgery centers, for elective care.
Ralph Giacobbe -- Citigroup -- Analyst
Okay, fair enough. Thank you.
Operator
Thank you. Next question today is coming from Gary Taylor from J.P. Morgan. Your line is now live.
Gary Taylor -- J.P. Morgan -- Analyst
Hi, good morning. Thanks for taking the question. Just a quick one. As we're trying to look through all the COVID impact and all the operating metrics, etc., just trying to get a sense of the underlying recovery in the commercial business that you've talked about. It's difficult to look at the revenue mix because that includes your MA business, it also includes COVID. So, is there any additional detail you could provide just on commercial adjusted admissions excluding COVID, commercial case mix index excluding COVID? Is there any additional detail or color you could provide on that?
Daniel Cancelmi -- Executive Vice President & Chief Financial Officer
Yeah. Hey, Gary. It's Dan. As I pointed out earlier, our COVID cases related to commercial payers or exchange payers is roughly 20% of the total COVID cases, which, as Saum pointed out, is slightly lower than our normal pure commercial mix. The other 80% is neither uninsured, Medicaid or Medicare. So, that's the mix of the volumes from a COVID perspective. The commercial...
Gary Taylor -- J.P. Morgan -- Analyst
I'm sorry. I'm sorry, I was saying, if you exclude COVID and we looked at underlying commercial adjusted admissions growth excluding COVID, is that up, down or flat year-over-year? I'm just trying to parse out the impact of the COVID on those.
Daniel Cancelmi -- Executive Vice President & Chief Financial Officer
Yeah, again, as I said earlier, the commercial trends are more favorable than the overall trends for the hospitals. So, if you see the monthly percent of recoveries for the overall admissions, the overall visits, surgeries, the commercial trends are more favorable than the overall trends.
Gary Taylor -- J.P. Morgan -- Analyst
Well, that's helpful. But if we exclude COVID admissions, you're down 20%. So, commercial is down less than 20%, I guess. That's a little [Indecipherable], too. Okay.
Daniel Cancelmi -- Executive Vice President & Chief Financial Officer
Yeah, I mean, like, again, obviously, the hospital volume trends in aggregate have not recovered to pre-COVID levels and that is the same thing with commercial. But the commercial rebound has been stronger than the overall rebound.
Saum Sutaria -- President & Chief Operating Officer
Okay. The only additional point I would add there is that the point I made before, which is I look more at surgeries and -- because that's not really COVID-related activity. And the strength in surgeries and, in particular, in commercial surgery is probably the best area to really look at with respect to the recovery. And as I pointed out earlier, our strength in surgeries and, in particular, to Dan's point, commercial recovering better in commercial surgeries is the strongest marker I have, when I look at a comparison across different lines of business there. And I feel very good about that.
Daniel Cancelmi -- Executive Vice President & Chief Financial Officer
And Saum, to that point, I know, Gary wasn't specifically asking about USPI, but we obviously had very favorable payer mix with our commercial mix outpatient -- outpacing governmental. More specifically, Q3 commercial was up 34 bps while Q3 governmental was down about 30 bps. So, overall, a positive trend in that regard.
Gary Taylor -- J.P. Morgan -- Analyst
That was revenue mix, right?
Daniel Cancelmi -- Executive Vice President & Chief Financial Officer
Correct.
Gary Taylor -- J.P. Morgan -- Analyst
Okay, thank you.
Ronald A. Rittenmeyer -- Executive Chairman & Chief Executive Officer
Okay. [Speech Overlap] Would you want to do one more?
Saum Sutaria -- President & Chief Operating Officer
Sure.
Ronald A. Rittenmeyer -- Executive Chairman & Chief Executive Officer
Let's do one more and then we'll wrap it. Operator, one more.
Operator
Certainly. Our final question today is coming from Frank Morgan from RBC Capital Markets. Your line is now live.
Ronald A. Rittenmeyer -- Executive Chairman & Chief Executive Officer
Hey, Frank.
Frank G. Morgan -- RBC Capital Markets -- Analyst
Good morning. This one's real quick. Dan, you called out your acceleration in your capex program, how you've upped those numbers. And I think one of the things you called out was COVID-related capex and I'm just curious what that would be. Thanks.
Daniel Cancelmi -- Executive Vice President & Chief Financial Officer
Hey, it's Dan. Yeah. So, the incremental investments that we're going to make is roughly $100 million. It's predominantly related to growth capital opportunities. Let me be clear. But there is some additional spend that we believe is necessary to appropriately care for COVID patients. I don't know, Saum, if there's anything else you want to add to that, but...
Saum Sutaria -- President & Chief Operating Officer
Yeah, I mean, examples of that would be, there are just equipment and supplies and things, some of which are more capital-related, think about some of the purchases of ventilators and other things that might be relevant in that space. The other infrastructure -- There's a little bit of infrastructure spend in there just because we -- as we pointed out earlier, we've been so disciplined about making sure that we minimize our infections of our own staff, because that is -- again, that is probably the most important marker in my mind of being able to maintain support in the hospital for always continuing elective work. So, we've put infrastructure into some of our hospitals, separation of COVID from non-COVID care areas and things of that nature so that it's more structural and again, it's on the spirit of keeping that environment safe and also creating an important perception for everybody who is in and out of the hospital that they're not going to be exposed.
Daniel Cancelmi -- Executive Vice President & Chief Financial Officer
[Indecipherable] added value of working. So, just good.
Ronald A. Rittenmeyer -- Executive Chairman & Chief Executive Officer
Okay. I think that's it. We appreciate everybody joining, I'm sure there will be some follow-ups. But we think, again, we had -- we feel we had a very good quarter and we appreciate the time you gave us to ask your questions. Hope they were clarifying and straight as could be. So, with that, I guess, operator, we'll conclude the session.
Operator
[Operator Closing Remarks]
Duration: 69 minutes
Call participants:
Regina Nethery -- Vice President of Investor Relations
Ronald A. Rittenmeyer -- Executive Chairman & Chief Executive Officer
Daniel Cancelmi -- Executive Vice President & Chief Financial Officer
Saum Sutaria -- President & Chief Operating Officer
Brett Brodnax -- President & Chief Executive Officer, USPI
A.J. Rice -- Credit Suisse -- Analyst
Joshua Raskin -- Nephron Research LLC -- Analyst
Eugene Kim -- Wolfe Research -- Analyst
Pito Chickering -- Deutsche Bank -- Analyst
Whit Mayo -- UBS -- Analyst
Brian Tanquilut -- Jefferies -- Analyst
Kevin Fischbeck -- Bank of America Merrill Lynch -- Analyst
Ralph Giacobbe -- Citigroup -- Analyst
Gary Taylor -- J.P. Morgan -- Analyst
Frank G. Morgan -- RBC Capital Markets -- Analyst
