Universal Health Services Q1 2024 Earnings Call Transcript

Presentation

[Operator]

Good day, and thank you for standing by. Welcome to the Universal Health Services First Quarter 2024 Earnings Conference Call. [Operator Instructions] Please be advised that today's conference is being recorded. I'd now like to hand the conference over to your first speaker today, Steve Filton, Executive Vice President and Chief Financial Officer. Please go ahead.

[Steve G. Filton, Chief Financial Officer, Executive Vice President, Secretary at Universal Health Services]

Thank you, and good morning. Marc Miller is also joining us this morning. We welcome you to this review of Universal Health Services results for the first quarter ended March 31, 2024. During this conference call, we will be using words such as believes, expects, anticipates, estimates and similar words that represent forecasts, projections and forward-looking statements. For anyone not familiar with the risks and uncertainties inherent in these forward-looking statements, I recommend a careful reading of the section on Risk Factors and forward-looking statements and risk factors in our Form 10-K for the year ended December 31, 2023. We'd like to highlight just a couple of developments and business trends before opening the call up to questions. As discussed in our press release last night, the company reported net income attributable to UHS per diluted share of $3.82 for the first quarter of 2024. After adjusting for the impact of the items reflected on the supplemental schedule, as included with the press release, our adjusted net income attributable to UHS per diluted share was $3.70 for the quarter ended March 31, 2024.

Our acute hospitals continue to experience strong demand for their services in the first quarter with adjusted admissions increasing 4.5% year-over-year on a same facility basis. When combined with the net revenue per adjusted admission increase of 4.6%, our acute care services net revenues increased by 9.6% during the first quarter of 2024, as compared to the first quarter of 2023. Despite these increases, we believe that both volumes and acuity in March were adversely impacted by the timing of Easter and spring break which occurred in March of this year compared to April of last year. In connection with the previously disclosed newly implemented Medicaid supplemental reimbursement program in Nevada, our acute care hospitals located in the state recorded approximately $38 million of aggregate incremental income during the first quarter of 2024. Meanwhile, premium pay in the quarter was $68 million as compared to $86 million in the first quarter of 2023. During the first quarter of 2024, same-facility net revenues in our Behavioral Health Hospitals increased by 10.4%, driven primarily by an 8.2% increase in revenue per adjusted day.

Adjusted patient day growth in the quarter was 2.0% over the prior year quarter. We believe the patient day volume was muted somewhat by the aforementioned calendar timing issues. Our cash generated from operating activities increased by $106 million to $396 million during the first quarter of 2024 as compared to $291 million during the same quarter in 2023. In the first quarter of 2024, we spent $209 million on capital expenditures and acquired 700,000 of our own shares at a cost of approximately $125 million. Since January 1, 2019, we have repurchased almost 27 million shares, representing 30% of our shares outstanding as of that date. As of March 31, 2024, we had $733 million of aggregate available borrowing capacity pursuant to our $1.2 billion revolving credit facility. I will now turn the call over to Marc Miller, President and CEO, for closing comments.

[Marc D. Miller, President, Chief Executive Officer, Director at Universal Health Services]

Thanks, Steve. In our year-end conference call, we said we envisioned 2024 as a year of continued strength in both of our business segments. And during the first quarter of 2024, both segments increased their operating margins when compared to the comparable quarter of 2023. We anticipated that acute care volumes would likely moderate to a degree, but remain robust compared to historical levels. We also believe the acuity trends will continue their recovery trajectory. In our Behavioral Health segment, we anticipated that patient day volumes would gradually improve over the course of the year, returning to a more historically normal level of growth in the 3% range. We noted that both of our business segments have experienced a significant increase in Medicaid supplemental payments which are helping to compensate for several years of inadequate reimbursement levels that have failed to keep up with the costs we had to incur to properly care for our patients. Overall, we're pleased with first quarter results.

We are now happy to answer questions at this time.

Questions and Answers

[Operator]

[Operator Instructions] Our first question comes from the line of Justin Lake of Wolfe Research. Your line is now open.

[Justin Lake, Analyst at Wolfe Research]

Thanks. Good morning. First question on your acute care volumes in the quarter. Just to your point, Steve, I think it's pretty clear the calendar had some impacts, January, February stronger, March weaker. So I'm curious if you can maybe share with us what you were seeing monthly or maybe kind of Jan, Feb versus March. And then how does April kind of starting to look versus March? Are you seeing it kind of back to January, February levels or somewhere in between? And then secondly, we know you've got a bunch of Medicaid dollars in Nevada, curious what ran through the behavioral business in the quarter. For instance, Mississippi, I think, had at a program that was put in, can you give us some color on the impact of those Medicaid provider tax dollars and behavioral? That would be helpful as well.

[Steve G. Filton, Chief Financial Officer, Executive Vice President, Secretary at Universal Health Services]

Okay, I'll try and tackle a bunch of different issues there. Yes, so definitely acute care volumes and behavioral volumes softened in March, I think, as a result of the Easter spring break timing. We're seeing some recovery in April, I would say April is probably volume-wise somewhere in between the January, February run rate and the March run rates. And I think that's what we would expect. I mean, the shortfall in admission and elective activity and surgical activity that we saw in March, I think we would largely expect to make up not necessarily completely in April, but mostly through the second quarter. And it seems like we're on track to do that.

As far as the Medicaid dollars, the one thing I would point out is we probably had in the quarter on the behavioral side, maybe $10 million to $15 million of out-of-period behavioral dollars that is we're catching up, mostly from 2023 as programs sort of refine their calculations, etc. So I think that's the major point in terms of the activity. Obviously, we disclosed in our at 10-Ks and 10-Q a great deal of detail about these Medicaid supplemental payments. And we'll update that disclosure in the 10-Q that we'll file in a week or so. Operator, we can get the next question.

[Operator]

Our next question comes from the line of Ann Hynes of Mizuho Securities. Your line is now open.

[Ann Hynes, Analyst at Mizuho Securities]

Hi, good morning. So obviously, you beat consensus EPS and EBITDA meaningfully. Can you tell us what you beat versus your internal expectations? Is my first question. And my second question is, inpatient grew higher than outpatient in the quarter. Could you let us know how much is from the 2-Midnight Rule?

[Steve G. Filton, Chief Financial Officer, Executive Vice President, Secretary at Universal Health Services]

Thanks, Ann. Yes, I mean, our internal budget for the quarter was not far off from consensus. I think maybe it was a little bit higher than consensus, so maybe two or three percentage points higher than consensus. But obviously, it was a successful quarter, both in terms of the third-party expectations as well as our own. As far as the 2-Midnight Rule and the impact on inpatient acute volumes, as best as we can tell, it did not have -- and I think the question is, is there a change in payer behavior that's resulting in a measurably increased amount of inpatient activity versus observation and our own data as well as we use a third party to help us adjudicate a lot of these of sort of, call them claims that are on the bubble of being inpatient or observation.

We use a third party to help us with that. And I think both our internal resources and our third-party consultants tell us that they're not seeing a significant or measurable change in the behavior of our payers that's really impacting our inpatient activity. So I would say that in our minds, most of the growth in acute care volumes in the quarter is exclusive of any change in payer behavior.

[Operator]

Our next question comes from the line of Stephen Baxter of Wells Fargo. Your line is now open.

[Stephen Baxter, Analyst at Wells Fargo & Company]

Yes, hi. Thanks for the questions. Two kind of quick ones, I guess. So first, the behavioral patient day, volume growth improvement that you're expecting throughout the year, I guess, just give us a little bit of color on leading indicators or potentially capacity opening up, I guess, like what is giving you the confidence to kind of point to that from here. And then secondarily, you obviously had this disclosure of a jury award during the quarter. I know that you discussed some measure of potential protection from insurance related to this. First, could you update us on where you stand from an insurance perspective related to that specific award? And any general comments you might offer about the litigation environment.

[Steve G. Filton, Chief Financial Officer, Executive Vice President, Secretary at Universal Health Services]

So in terms of your first question about behavioral patient days and behavioral patient day growth, I think as you alluded to in your question, it improved slightly from the pace of the last few quarters, our expectation is that it will continue to improve during the year. Incrementally, I think Marc mentioned that our underlying guidance for the year assumes we'll get to like a 3% patient day growth level. What gives us that confidence is simply that, as we've said, many times over the last several years as we believe the underlying demand is there. That's evident in the amount and volume of inbound inquiries we get on the Internet and our 800 numbers, etc. And it's really about our ability to staff sufficiently to be able to treat that volume.

We've mentioned a few other I think dynamics that have muted that volume a little bit in the last few quarters, including some specific residential treatment facilities that we believe continue to improve including the impact of Medicaid disenrollment, which I think we think is stabilizing, etc. So I think it's all those factors together that give us the confidence that behavioral volume will continue to grow incrementally throughout the year. Your second question was around the verdict in a malpractice case in Illinois that we disclosed in an 8-K a few weeks ago. That verdict was as we noted in the 8-K, unprecedented, it was unprecedented, both in terms of our own history and cases with similar fact patterns, it was unprecedented in terms of verdicts in that specific jurisdiction, etc.

And so we think there still is a great deal of uncertainty around how that specific verdict will be ultimately adjudicated and as a result, other than the disclosure that we had in the 8-K and in the press release, we'll have in our 10-Q, we haven't really had any measurable impact on our financial statements until there is some level of greater certainty around what the ultimate outcome will be. From an insurance perspective, we disclosed in our Qs and Ks, our insurance coverage by year. This is a 2020 incident, we disclosed that we had $250 million of commercial insurance for that year. The bulk of that insurance around $225 million is still available for coverage.

[Operator]

Thank you. Our next question comes from the line of Pito Chickering of Deutsche Bank. Your line is now open.

[Pito Chickering, Analyst at Deutsche Bank Aktiengesellschaft]

Yes, good morning. Can you talk about the acute opex changes that you saw in this quarter? How much did physician expenses increased year-over-year? And is this the right level going forward and any other pressure points at the OpEx we should be thinking about?

[Steve G. Filton, Chief Financial Officer, Executive Vice President, Secretary at Universal Health Services]

Yes. So I think, Pito, especially on the acute side, the increase in other operating costs are primarily driven by physician expense which we said for the year would increase by about 5% or 6%, and we believe that will still be the case. But because physician expense continue to increase every quarter last year, and we believe will be relatively flat this year, meaning flat quarter-to-quarter, the increase over last year will diminish as we get to the end of the year. And again, I think we're on target to get to that sort of 5% or 6% growth over the prior year.

But in Q1, that growth was more like 12% or 13%. And then the other, I think, driver of opex increase, particularly in the acute division was increased claims having to do with our insurance subsidiary and that's mostly having to do with increased premiums, the insurance subsidiary, was that sort of a breakeven level for the quarter, which is where we had it budgeted. So nothing unexpected there for our point of view.

[Pito Chickering, Analyst at Deutsche Bank Aktiengesellschaft]

Okay. And then on -- a follow-up to Justin's question on supplemental payments. I guess for $10 million to $15 million from prior two periods. But looking out into '24 or '25, what states do you think could be expanding or adding sort of new payments that could impact your behavioral throughout the year?

[Steve G. Filton, Chief Financial Officer, Executive Vice President, Secretary at Universal Health Services]

Yes. So what I would say is we've often pointed out, and I think there are a couple of analysts on this call who will routinely point out that over the last several years, especially our original forecast of supplemental payments have tended to only increase as the year has gone on as states either implement new programs or refine their existing programs and calculations and I think that's our expectation for this year as well. One of the tricky parts about this is I think we tend not to disclose what states they are or what expectations might be until the state really goes public or gets the approvals they required or goes public with their calculations. So we do believe, I think as we said on the last call, and I'll reiterate today, I think we do expect a number of states to implement either new programs or expand existing programs by the end of the year, but we'll give that detail as it becomes more certain in our public filings.

[Pito Chickering, Analyst at Deutsche Bank Aktiengesellschaft]

Great. Thanks so much.

[Operator]

Thank you. Our next question comes from the line of A.J. Rice of UBS. Your line is now open.

[A.J. Rice, Analyst at UBS Group]

Thanks. Hi everybody. Obviously, with the strong revenue number, that gives you leverage down the income statement. But I wondered if you look at labor, both permanent and your premium labor. Can you give us a little sense of what the underlying trends are year-to-year wage increases, how it's working out with your premium labor outlay and then similarly, I'll ask on the first second question. Pricing was strong in the quarter. Obviously, that was helped on the acute side by the supplemental payments, any updated thoughts on where commercial rate increases are coming out and the extent to which you think exchange-related coverage as people maybe pick up exchange coverage versus Medicaid is impacting what you're seeing there?

[Steve G. Filton, Chief Financial Officer, Executive Vice President, Secretary at Universal Health Services]

Yes. So again, a few different issues here. I'll try and address them discretely. Yes, I mean I think clearly, what the income statement reflects as you alluded to, A.J., is more operating leverage and efficiency on the labor line. I think it's a result of a few different things, premium and pay. As I said in my opening comments, is down roughly $20 million from the same quarter last year. I think we're seeing wage rate inflation decelerate from the peak levels that it was running at the height of the pandemic. I think that's helping. I also think we've made a number of productivity adjustments in both business segments over the course of the last six months. As we came out of the pandemic, I think we reevaluated our productivity in both segments, particularly in our nonclinical areas, some of which I think maybe grew ahead of the actual need for those resources during the pandemic. As far as pricing goes, we continue to get, I think, reasonable price increases in our contractual rates.

I think the bigger issue, quite frankly, on the acute side, especially, is more this issue of as the managed care companies see their margins under pressure, we have tended in the past to see greater levels of denial activity, patient status changes, etc. We saw a lot of that in 2023. I think that activity has stabilized some in the fourth quarter and in the first quarter of this year, but it's something that we're watching very carefully. We are seeing, I think, as a result of Medicaid disenrollments, more patients moving to exchange coverage. I think that tends to be a net positive on the acute side because I think exchange coverage reimbursement tends to be slightly better than Medicaid or in some cases measurably better. On the behavioral side, I think it's a bit of a toss-up because a lot of these exchange coverages have pretty significant co-pays and deductibles.

And given the fact that behavioral care on an absolute basis tends to have a much smaller bill. I think we find that patients who have exchange coverage often will not be able to cover their or the bill will not cover their co-pays and deductibles. So sometimes, that switch from Medicaid to an exchange coverage is not a favorable development on the on the behavioral side, and May, I think, contribute a little bit to the slower growth in patient pay volumes on the behavioral side.

[A.J. Rice, Analyst at UBS Group]

Interesting. Okay. Thanks so much.

[Operator]

Our next question comes from the line of Ben Hendrix of RBC Capital Markets. Your line is now open.

[Ben Hendrix, Analyst at RBC Capital Markets]

Great. Thank you very much. Just a quick follow-up on the Illinois litigation. I appreciate that this is unprecedented and different, in fact, and jurisdiction from Acadia settlement, but that was also kind of equally unprecedented. I was just wondering if this is changing at all your approach to the RTC business, your strategy, capital allocation and how you expect to kind of grow in your approach to behavioral health over the long term?

[Steve G. Filton, Chief Financial Officer, Executive Vice President, Secretary at Universal Health Services]

No, I think it would be premature, then. Again, as I commented earlier, I think that there still is a great deal of uncertainty surrounding this particular case and verdict that we had. I'm certainly not an expert and wouldn't comment in any great detail on the case that Acadia had other than to comment that it was a different state, it was the case with multiple plaintiffs. There were multiple cases. Our case was in a different jurisdiction, a single plane of a single incident, etc. So yes, I think broadly in response to your question, no, I don't think our approach to the business is being changed at the moment as a result of this verdict. We are very focused on the things we need to do to work through this verdict and to challenge it and appeal it if necessary, at several different levels of the judicial system. But at the moment, I don't think it's having an impact on the way we think about the business.

[Ben Hendrix, Analyst at RBC Capital Markets]

Thank you.

[Operator]

Thank you. Our next question comes from the line of Kevin Fischbeck of Bank of America. Your line is now open.

[Kevin Fischbeck, Analyst at Bank of America]

Great. Thanks. I was wondering if you can talk a little bit about margins. I guess both segments saw some nice margin improvement in the quarter. You've talked about a significant margin opportunity in both segments of time. Just want to get a little more color update about how you think about build to an opportunity for margins, the pace of that margin improvement? And it does feel like -- and I don't know if this was in your original assumption, but it does feel like the supplemental payments are coming in maybe better than one might have thought a year or two ago. So I want to get your thoughts about how that might impact your view on where margins ultimately can be? And then I guess if you think about where we are versus where it could be, what are the main levers in each segment to kind of get from here to there.

[Steve G. Filton, Chief Financial Officer, Executive Vice President, Secretary at Universal Health Services]

Yes. So Kevin, we have said for some time that we felt like the margin deterioration that we saw during the pandemic could and would largely be recovered in both business segments as we return to sort of more normal levels of growth, and I think you specifically have pointed out that acute care volumes broadly, not just ours, still haven't necessarily returned to prepandemic levels. So we still think there is a decent amount of runway there for continued acute care volume growth as well as behavioral volume growth, which I addressed in a previous question. I think the benefit there is that we continue to have this strong revenue performance. I do think expenses are being better controlled, both by us in terms of our own in actions and things that we control, productivity, etc, but I also think broadly, wage inflation is becoming more manageable. Physician expense, which was a huge drag of the increase in physician expense in '23, I think it's not going to be a drag for the full year of '24.

And so I think that's -- all those are opportunities for margin improvement. Obviously, as your question suggests, the increase in Medicaid supplemental payments are a significant opportunity as well. I think as Marc's comments reflected in our prepared remarks, we largely feel that those increased Medicaid reimbursements are making up for an adequate reimbursement over the last several years, but if you put it in the context of margin improvement, they should be very helpful because at least at the current moment, there's not new or incremental expense associated with most of those Medicaid supplemental payments. So it's a big help in recovering those margins that deteriorated over the past few years because they were inadequately reimbursing us for our cost increases.

We'll see, I mean, obviously, the first quarter was a significant improvement, as I alluded to in an earlier question, over our expectations. We'll see how the rest of the year plays out. But hopefully, we'll recover more of that margin deterioration than we originally anticipated in our guidance, but we'll see how the rest of the year plays out before making that judgment.

[Kevin Fischbeck, Analyst at Bank of America]

Great. Thanks.

[Operator]

Thank you. Our next question comes from the line of Jason Cassorla of Citi.

[Jason Cassorla, Analyst at Smith Barney Citigroup]

I wanted to follow up on the supplemental payments and the acceleration there. Clearly, you guys are benefiting. But I guess your local market competitors with by design benefiting as well. So I guess I'm just curious if you're seeing any changes from a competitive standpoint either competitors accelerating build-out of the outpatient or anything along those lines? And then if I could follow up quickly just on the Illinois litigation. I know there's a number of unknowns there on how that could play out. But does that change how you're thinking from a share repo argument or capital deployment in the near term as you wait to see how that all evolves. Any help there would be great.

[Steve G. Filton, Chief Financial Officer, Executive Vice President, Secretary at Universal Health Services]

Yes. So in terms of your first question, Jason, I don't know that in any of our markets, we've detected or recognized a significant change in our competitive behavior as a result of the increase in supplemental payments. I'll make the point that, obviously, the supplemental payments tend to benefit as they're intended to providers who are providing more service to Medicaid patients have higher Medicaid utilization. I think that's why we struggled a little bit more during the pandemic. I think we tend to have a slightly higher Medicaid utilization than some of our public peers. So I think we're benefiting from that now. But in terms of our local market now, I don't know that, again, the Medicaid supplemental payments are specifically affecting competitive behavior.

Just like I don't know that it's specifically affecting our strategic sort of moves or actions in a specific market. As far as the Illinois impact on capital deployment or specifically share repurchase, I'll sort of reiterate the same comment that I made before. I think it's too early for us to really make any sort of -- or have any sort of specific reaction until we see a further diminution of the uncertainty surrounding how this verdict and case will ultimately be adjudicated. At some point, it could have an impact but I think at the moment, we're waiting at a minimum until we at least see the outcome from post-trial motions at the trial judge and trial court level. And so at a minimum, I think we'll wait and see what happens there before deciding what our next steps are.

[Jason Cassorla, Analyst at Smith Barney Citigroup]

Great. Thank you.

[Operator]

Thank you. Our next question comes from the line of Whit Mayo of Leerink Partners. Your line is now open.

[Whit Mayo, Analyst at Leerink Partners]

Hey thanks. Good morning Steve.maybe just comment on the Medicaid rule that was released this week on state-based programs. Maybe too early to have much insight, but it seems like some positives and some less positive things. Just curious how your team and legal advisers are looking at this.

[Steve G. Filton, Chief Financial Officer, Executive Vice President, Secretary at Universal Health Services]

Yes. So I mean we were encouraged with the fact that in this rule, Medicaid did not place a cap on these supplemental programs. Instead, they focused -- as they have in the past, I don't think this was a new focus there, but they focused on these hold harmless agreements, which they have historically objected to. I'm certainly not an expert -- a legal expert in this regard. But I do know that we've certainly used legal experts and consultants and are aware of consultants who will adamantly argue that CMS just is wrong on this particular issue and on the legality of these hold harmless arrangements. But regardless of -- so I think there's a chance that CMS' objection to these hold harmless agreements might be successfully challenged legally over the course of the next several years. In any event, I think it was encouraging that CMS said that they were not going to essentially go after or enforce any actions against these hold harmless agreements until 2028, which I think means that if states are convinced that these arrangements are not going to withstand sort of legal scrutiny, they have time to change them.

So I would make the point, we did a quick analysis and think that maybe about 1/3 of the supplemental payments we currently receive are under these hold harmless agreements that CMS has objected to. But 2/3 are not. And we think, again, that CMS has left the stage plenty of time to restructure their arrangements if they're convinced of these hold harmless agreements will not hold up under legal scrutiny. So I think generally, we found that all to be pretty encouraging in terms of the flexibility the states will have and the time they'll have to respond to this new rule.

[Whit Mayo, Analyst at Leerink Partners]

That's helpful. And just one other quick one. Just thinking about the opening of West Henderson later this year. Is that still a good timetable and maybe the P&L consideration, start-up losses, and I'm kind of curious how you think about how the volume may get redistributed in the market once that hospital opens.

[Steve G. Filton, Chief Financial Officer, Executive Vice President, Secretary at Universal Health Services]

So West Henderson is scheduled to open late in the year, maybe in late November, December. So it shouldn't have much of an impact, there will be some level of preopening costs and then a month or two of probably operating losses as it opens. I think we didn't really highlight that in our call a couple of months ago, in part because I think we have a view that continued improvement of our hospital in the renal market will largely offset that. And as a consequence, neither was likely to have a material impact on this year's results. There's some amount of cannibalization that will take place, meaning we'll take some patients probably from our existing Henderson Hospital. But the real play for West Henderson is significant population growth in that area that we think will allow the hospital to have a very successful opening. Quite frankly, the opening of Henderson at this point, I think, five years ago was very successful for the same reasons. And I think we're looking for West Henderson to have a very similar experience when it opens late this year.

[Whit Mayo, Analyst at Leerink Partners]

Okay. Thanks.

[Operator]

Thank you. Our next question comes from the line of Sarah James of Cantor Fitzgerald. Your line is now open.

[Sarah James, Analyst at Cantor Fitzgerald]

Thank you. Can you clarify the $5 million sequential uptick in premium pay, was that related to the acute volume strength? Then does your $50 million a quarter of premium pay goal assume a version to normal acute volumes? And how do you think about strategy and time line to get to that $50 million?

[Steve G. Filton, Chief Financial Officer, Executive Vice President, Secretary at Universal Health Services]

Yes. So I actually think, Sarah, that the $68 million in premium pay in Q1 is pretty similar to what we've been running the last few quarters. You're right, we have talked kind of about a goal of getting into sort of the mid-50s. But I think what's prevented us from doing that is these really robust acute care volumes. And I'll make the point that the 4.5% adjusted admission increase in Q1 of this year is compared to, I think, in excess of a 10% increase in adjusted admissions last year's first quarter. So you're really talking about, I think, some pretty historically high acute care volume numbers.

And yes, I think we acknowledge that it will be difficult to get much below the premium pay levels we're currently running at unless acute care volumes moderate. And quite frankly, we'd be perfectly happy if they don't. I think at these levels of acute care -- at this level of acute care volumes, we're relatively satisfied with having to run this level of premium pay.

[Sarah James, Analyst at Cantor Fitzgerald]

Great. Thank you.

[Operator]

Thank you. Our next question comes from the line of Joshua Raskin of Nephron Research. Your line is now open.

[Joshua Raskin, Analyst at Nephron Research]

Hi, thanks. Good morning. I was wondering if you could give a broader update on capex spending and maybe capacity increases in specific areas of focus and then just a quick follow-up on Las Vegas and West Henderson opening. I'm curious if Las Vegas on the acute care side, volumes or demand there running above company average? And maybe just a little bit more color on sort of shorter-term trends there.

[Steve G. Filton, Chief Financial Officer, Executive Vice President, Secretary at Universal Health Services]

Sure. So I think from a capex perspective, Josh, I think we continue to invest on the acute side in those areas where I think acute invasion hospitals really differentiate themselves, meaning emergency room services, emergency room capacity, surgical services, both in and outpatient, and again, for the higher acuity, higher-end services that we don't have as much competition in. But we also continue to invest in outpatient. We have a very successful freestanding emergency department initiative that has been underway for a number of years. I think we'll finish this year with probably 30 freestanding EDs around the country, whereas five years ago, I think we didn't have any, and we can also continue to invest in some freestanding surgical services facilities, freestanding imaging centers, etc.

On the behavioral side, it's mostly building more inpatient capacity now that we are at least in many markets and many facilities, more fully staffed, but also in that business, investing in freestanding outpatient developments, telemedicine, addiction treatment, etc. So I think, again, in both business segments, the capex really runs the gamut of the sort of full service continuum at our facilities and our integrated providers tend to provide in their markets. As far as the specific questions about Las Vegas, look, I think one of the comments that we've made over the last several years is that one of the reasons why I think we've been slower to recover those margins that we talked about in the previous question than some of our peers is that some of the geographies around the country that have recovered more quickly from the pandemic, Texas and Florida, most specifically, while we have a presence in those geographies, we tend to have a bigger footprint in places like Nevada, California, the addition of Columbia that have tended to recover more slowly from the pandemic just from a broader economic perspective. But I think in the last couple of quarters, the recovery trajectory in Nevada has definitely accelerated and separate and apart from the Medicaid supplemental program, which obviously is quite helpful in that market or that state. We've seen, I think, fundamental business metrics improve pretty dramatically in the last couple of quarters.

[Joshua Raskin, Analyst at Nephron Research]

Perfect. Thanks.

[Operator]

Thank you. [Operator Instructions] Our next question comes from the line of Andrew Mok of Barclays. Your line is now open.

[Andrew Mok, Analyst at Barclays]

Hi, good morning. I think you commented that the quarter was above your internal expectations. You're expecting behavioral volumes to improve from here, and there's potential upside to initial forecast for supplemental payments. So just putting all those together, any updated thoughts on where you think you sit within the unchanged guidance for the year.

[Steve G. Filton, Chief Financial Officer, Executive Vice President, Secretary at Universal Health Services]

Sure, Andrew. I mean, clearly, just from a mathematical perspective, the amount that we exceeded our own internal budget and consensus numbers for the first quarter would already put us on the trajectory towards the high end of our guidance. I think most people know, but I'll just repeat for everybody's sake. We had never revised guidance after the first quarter. It's just something that we don't generally think is a kind of a prudent thing to do. I think if the trends continue, however in Q2, that's certainly a possibility, guidance revision at the end of Q2 if these trends continue. Again, I think the trends that I would specifically highlight were better than we expected in Q1 of our acute care volumes, which I think we thought might moderate a little bit more than they actually did and behavioral pricing, which I think we thought might moderate a little bit more than they did. Obviously, we're pleased that neither did, we're focused on keeping both of those metrics as high as they can be. But to me, that's where we'll watch most closely in Q2. If those metrics remain strong and steady in Q2, I think it's much more likely that we'd have a guidance revision at that point in time.

[Andrew Mok, Analyst at Barclays]

Great. And then just a follow-up. I think you commented on intra-quarter in April volumes in the acute segment. Just hoping you could do the same thing in the behavioral segment and maybe comment on trends exiting the quarter to help support the higher growth outlook?

[Steve G. Filton, Chief Financial Officer, Executive Vice President, Secretary at Universal Health Services]

Yes. I think I forget if the comments that I made were specifically about the acute segment. But I think the trends more similar in both. I think I commented in some conferences earlier this quarter that the behavioral business got off to a bit of a slow start with some bad weather -- in bad winter weather in states that don't necessarily usually expect bad winter weather in the south central part of the country. But April volumes recovered in late January and certainly in February, but I think have the same calendar issues as the acute segment did in March, softer volumes, etc, particularly in that child and adolescent population, which tends to really soften when school is out. But yes, I mean I think I'd make the same comment. I think we would expect to recover that softness if not in April, but then over the course of the second quarter. And I think Marc alluded to in his prepared comments that our general expectation at the beginning of the year was that behavioral volumes would incrementally improve as the year went on, and that's still our expectation.

[Operator]

I'm showing no further questions at this time. I would now like to turn it back to Steve Filton for closing remarks.

[Steve G. Filton, Chief Financial Officer, Executive Vice President, Secretary at Universal Health Services]

We'd just like to thank everybody for their time and look forward to speaking with everybody next quarter.

[Operator]

[Operator Closing Remarks]

Participants

Corporate Executives

• Steve G. Filton, Chief Financial Officer, Executive Vice President, Secretary
• Marc D. Miller, President, Chief Executive Officer, Director

Analysts

• Justin Lake, Wolfe Research
• Ann Hynes, Mizuho Securities
• Stephen Baxter, Wells Fargo & Company
• Pito Chickering, Deutsche Bank Aktiengesellschaft
• A.J. Rice, UBS Group AG
• Ben Hendrix, RBC Capital Markets
• Kevin Fischbeck, Bank of America Co.
• Jason Cassorla, Smith Barney Citigroup
• Whit Mayo, Leerink Partners
• Sarah James, Cantor Fitzgerald
• Joshua Raskin, Nephron Research
• Andrew Mok, Barclays PLC